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Outlines  of  Psychiatry 


INTRODUCTORY  LESSONS 


Designed  for  the  use  of 
Students  of  Medicine 


BY 


CHARLES   GILBERT   CHADDOCK,  M.D. 

Professor  of  Diseases  of  the  Nervous  System 

Marion-Sims-Beaumont  College  of  Medicine,  Medical  Department 

of  St.  Louis  University. 


r 


St.  Louis: 
Commercial  Printing  Company 

1904 


I 

B 

BIOL-UB. 


COPYRIGHTED  BY  CHARLES  GILBERT  CHADDOCK,  M.D. 


TABLE  OF  CONTENTS. 


LESSON  PAGE 

I     Introduction i 

II     Historical  Review 8 

III     Mental  Physiology 15 

IV     Elementary  Psychology 23 

V     Elementary  Anomalies  of  the  Mind  28 

VI     Delusions  38 

VII     Anomalies  of  the  Feelings 46 

VIII     Disordered  Acts.— The  Will 55 

IX     Anomalies    of    General    Bodily    Functions ;    Some 

Special  Nervous  Signs  and  Symptoms 63 

X     Some  Signs  and  Symptoms  of  Organic  Nervous  Dis- 
ease.— (Continued.) 71 

XI     The  Deep  and  Superficial  Reflexes 79 

XII     The  Etiology  of  Insanity 89 

XIII  The  Course  and  Termination  of  Insanity 97 

XIV  Classification  of  Insanity 103 

XV     Emotional  Depression  (Melancholia) 111 

XVI     Emotional  Exaltation  (Mania) 124 

XVII     Hallucinatory  Insanity  (Delirium) 133 

XVIII     Acute  Dementia.     General  Remarks  on  the  Simple 

Insanities 140 

XIX     Degenerate   Insanities 147 

XX     Paranoia 155 

XXI     Paranoia. — (Continued.) 164 

XXII     Epileptic  Insanity 172 

XXIII  Hysteric  Insanity 180 

XXIV  Insanity  Due  to  Material  Causes.     Toxic  and  Or- 

ganic Insanity 188 

XXV     Toxic  and  Organic  Insanities.     Alcoholic  Insanity. 

(Continued.)  197 

XXVI     Dementia  Paralytica 205 

XXVII     Dementia  Paralytica. — (Continued. ) 213 

XXVIII     Syphilitic,  Senile,  and  Other  Insanities  Due  to  Gross 

Cerebral  Disease 223 


PREFACE 


These  lessons  contain  the  substance  of  lectures  delivered 
to  the  senior  class  of  the  Medical  Department  of  St.  Louis 
University  during  the  first  semester  of  the  college  year. 
They  are  intended  as  an  introduction  to  more  extended  text- 
books of  insanity,  and  as  an  aid  to  a  better  understanding 
of  cases  of  mental  disease  presented  in  clinical  demonstra- 
tions. They  cover  only  the  more  important  parts  of  the  sub- 
ject. It  is  hoped  that  in  this  form  these  "Outlines"  will 
lighten  the  student's  task  and  awaken  his  interest  in  a 
branch  of  medical  study  that  is  too  often  thought  to  belong 
exclusively  to  the  alienist. 

AUTHOR. 


LESSON  I. 


Introduction. 

Insanity  is  a  condition  of  mind  that  is  strikingly  or 
demonstrably  at  variance  with  the  normal  and  usual  condi- 
tions of  mind  manifested  by  the  majority  of  individuals  of 
like  race  and  training,  which  can  be  shown  to  have  a 
pathologic  cause. 

Disease  of  the  mind,  mental  disease,  mental  unsound- 
ness, lunacy,  alienation, — are  the  common  synonyms  of  in- 
sanity. 

Psychiatry  is  the  science  of  insanity,  including  symp- 
toms, pathology,  psychopathology,  diagnosis,  prognosis, 
treatment,  etc.,  and  is  in  contrast  with  psychology;  just  as 
pathology  is  in  contrast  with  physiology. 

The  mind  is  a  manifestation  of  activities  that  have  their 
seat  in  the  cortex  of  the  brain;  therefore  all  modifications 
of  usual  or  normal  mental  states  must  be  due  to  unusual 
or  abnormal  activities  or  conditions  of  the  cortex  of  the 
brain. 

Insanity  is  a  symptom  of  disease;  but  in  common  lan- 
•  guage  insanity  is  spoken  of  as  a  disease,  just  as  paralysis, 
'  though  only  a  symptom,  is  often  called  a  disease. 

Technically,  temporary  disturbances  of  the  mind  like 
the  delirium  of  fever,  drunkenness,  somnambulism,  etc., 
are  not  considered  insanity,  because  of  their  short  duration ; 

1 


2  OUTLINES   OF   PSYCHIATRY. 

but  they  are  none  the  less  abnormal  mental  states  due  to  cor- 
tical disturbance,  and  the  frequency  with  which  they  form 
the  beginning  of  a  formal  insanity  shows  how  necessary  it 
is  to  study  them. 

If  all  forms  of  insanity  are  symptoms  of  disturb- 
ances of  the  activity  of  the  cortex  of  the  brain,  it  does  not 
follow  that  all  lesions  of  the  cortex  inevitably  cause  insanity. 
Often  focal  or  circumscribed  lesions  of  the  cortex  have  little 
or  no  effect  on  the  mind ;  but  diffuse  lesions  of  the  cerebral 
cortex  are  practically  always  attended  by  mental  disturbance, 
and  therefore  it  may  be  theoretically  concluded  that  insanity 
is  the  result  of  diffuse  pathologic  processej_jg^conartibns 
affecting  the  corfe"x~of"-the  "brain. 

The  pathology  of  the  cerebral  cortex  and  the  insane  states 
of  mind  have  thus  far  defied  every  effort  to  bring  them 
into  relation.  In  other  words,  no  one  can  tell  from  the  state 
of  the  cortex  observed  at  autopsy  what  the  mental  symptoms 
were  during  life,  except  in  the  most  indefinite  way ;  as,  ~for 
example,  dementia,  or  general  loss  of  mind,  predicated  from 
general  cortical  atrophy. 

The  reason  for  this  lies  in  the  fact  that  there  is  yet  no 
knowledge  of  the  nature  of  the  normal  processes  of  which 
mind  is  a  manifestation.  Many  forms  of  insanity  are  made 
up,  not  of  signs  of  loss  of  mind,  but  of  disturbances  of 
relation  of  elementai^^nsntalphenomena,  which  taken  singly 
do  not' differ  from  those  normallylnanifested ;  and  they  are 
therefore  necessarily  as  inscrutable  as  normal  mental  phe- 
nomena. 

Alienists  and  jurists  alike  deplore  the  lack  of  a  satisfac- 
tory definition  of  insanity — one  that  would  serve  in  path- 
ology and  in  the  courts.  In  the  nature  of  the  case  none  can 
ever  be  made.     The  jurist  demands  a  definition  that  will 


INTRODUCTION.  3 

enable  him  to  decide  the  question  of  moral  responsibility, 
which  the  law  declares  absent  in  insanity ;  the  alienist  seeks 
a  definition  of  insanity  that  will  fit  every  case  of  mental 
alienation,  and  render  it  possible  for  a  novice  to  make  a 
diagnosis  of  insanity. 

There  is  no  reason  to  think  that  a  common  ground  of 
accord  will  ever  be  found :  the  need  of  one  side  is  moral 
and  therefore  ideals  the  need  of  the  other  side  is  material 


(physical)  ;  the  two  cannot  be  harmonized. 

The  symptomatology  of  insanity  is  practically  and  theo- 
retically infinite,  and  no  definition  from  a  medical  point  of 
view  can  ever  be  more  than  a  very  indefinite  generalization. 

The  courts  will  continue  to  decide  the  question  of  moral 
responsibility  by  philosophic  principles ;  the  alienist  will  con- 
tinue to  study  symptoms  of  abnormal  activity  of  the  cortex 
of  the  brain. 

A  medical  witness  should  never  attempt  a  definition  of 
insanity  in  a  court  of  law,  but  limit  himself  to  consideration 
of  the  question  of  mental  symptoms  as  indicating  disease  of 
the  brain;  or  as  simulated  to  cause  a  belief  in  the  existence 
of  insanity. 

The  existence  or  absence  of  moral  responsibility  is  a 
question  about  which  an  opinion  may  be  expressed  at  request. 
There  are  cases  in  which  no  doubt  exists :  idiots  and  some 
profoundly  demented  individuals  have  no  more  moral  respon- 
sibility than  "a  newborn  infant.  The  difficulty  arises  in 
cases  in  which  the  mind  is  active;  and  in  such  instances  a 
decision  concerning  the  existence  of  moral  responsibility  or 
freedom  of  the  will  must  rest  on  opinion  rather  than  upon 
fact. 

Insanity  is  very  often  a  plea  put  forward  as  an  excuse 
for  crime;  and  thus  arises  the  difficulty  for  the  medical 


4  OUTLINES   OF   PSYCHIATRY. 

witness.  A  specious  kind  of  simulation  of  mental  symptoms 
is  very  easy  for  almost  anyone,  and  therefore  real  and  as- 
sumed insanity  may  appear  very  much  alike  to  the  inexperi- 
enced observer.  This  is  not  alone  true  of  insanity;  it  is 
observed  in  many  other  kinds  of  morbid  symptomatology. 
It  is  especially  true  in  cases  of  physical  injury,  when  pecu- 
niary responsibility  of  a  railroad  company,  a  municipality,  or 
an  accident  insurance  company,  is  involved.  The  problem  in 
these  cases  is  easier  to  solve  because  there  is  always  a  physical 
basis  (objective)  of  examination ;  while  in  a  case  of  insanity, 
the  physical  basis  is  often  wanting,  and  judgment  must  be 
founded  on  subjective  symptoms  only.  However,  the  suc- 
cessful assumption  of  insanity  is  possible  only  in  one  well- 
versed  in  knowledge  of  mental  disease;  for  the  forms  of 
insanity,  from  a  clinical  point  of  view,  present  well-defined 
characteristics  in  development,  course,  symptomatology,  and 
termination,  knowledge  of  which  permits  a  skilled  observer 
to  distinguish  with  more  or  less  facility  between  the  spurious 
and  the  real  symptoms. 

Insanity  is  often  attended  by  physical  symptoms  which 
call  for  careful  study  and  treatment.  There  are  symptoms 
of  a  physical  kind  that  depend  directly  on  the  nervous  system ; 
there  are  others  that  indicate  abnormal  function  of  the  vari- 
ous organs  of  vegetative  life, — nutrition,  digestion,  circula- 
tion,— which  must  be  studied  either  as  cause  or  effect. 

The  influence  of  the  mind  on  the  body  is  so  real  that  it 
must  always  be  taken  into  consideration  in  the  study  of  dis- 
ease, and  all  the  more  when  abnormal  mental  states  are  the 
predominating  symptoms  of  disorder  of  the  organism. 

A  mental  shock,  sudden  sorrow,  financial  disaster,  dis- 
appointment of  expectations,  may  induce  a  state  of  depression 
■  that  arrests  temporarily  many  of  the  organic  functions — 


INTRODUCTION.  5 

appetite,  digestion,  muscular  tonicity  with  consequent  relaxa- 
tion of  the  muscles,  voluntary  and  involuntary — which,  if 
continued,  leads  to  malnutrition,  anemia,  and  marked  loss 
of  weight.  Inactivity  of  the  organic  functions  is  prone  to 
cause  conditions  favoring  the  development  of  poisons  (auto- 
intoxication) in  the  system,  as  a  result  of  defective  oxidation 
and  elimination;  and  toxines  thus  developed  only  serve  to 
augment  the  original  depression  of  the  mental  functions. 

But  defective  elimination,  oxidation,  etc.,  arising  pri- 
marily in  the  vegetative  organs,  are  capable  of  inducing  by 
means  of  auto-intoxication,  states  of  mental  depression, 
which  again  react  on  the  vital  functions,  and  thus  impede 
a  return  to  the  normal  state. 

On  the  other  hand,  a  state  of  exaltation  of  mental  feeling 
may  be  the  result  of  mental  shock,  or  of  exogenous  or  endo- 
genous intoxication,  either  directly,  or  following  a  primary 
state  of  mental  depression.  The  immediate  effect  of  such  a 
state  of  exaltation  on  the  bodily  functions  is  seen  in  an  exalta- 
tion or  facilitation  of  them :  the  circulation  is  accelerated ; 
the  appetites  of  all  kinds  are  increased ;  the  facial  expression 
is  livelier ;  the  muscle-tone  is  increased ;  so  that  there  results 
over-expenditure  of  physical  force  with  loss  of  weight,  be- 
cause waste  is  in  excess  of  assimilation. 

Mental  disorder,  while  always  a  manifestation  of  disease, 
must  be  considered  always  with  reference  to  two  causal  fac- 
tors :  the  exciting  cause  and  the  inherent  condition  of  the 
individual.  One  person  is  an  easy  prey  mentaTly~"fo'  arrnost 
any  disturbing  factor;  another  supports  almost  any  psychic 
shock  without  disturbance  of  his  mental  equilibrium.  Prac- 
tically, this  difference  can  be  appreciated  only  after  the  event. 

Again,  there  are  certain  causes  of  insanity  which  act  in- 
dependently   of    individual    predisposition, — pre-eminently 


6  OUTLINES  OF   PSYCHIATRY. 

syphilis  as  a  causal  factor  in  the  production  of  paretic  de- 
mentia, or  paresis  so-called. 

In  the  category  of  persons  predisposed  to  insanity  as  a 
result  of  inherent  conditions,  are  those  that  develop  an  in- 
sane condition  without  apparent  external  cause.  It  is  these 
cases  that  make  clear  the  importance  of  iieredity  as  a  cause 
of  insanity. 

In  certain  cases  of  insanity  without  appreciable  cause, 
we  are  at  once  led  to  incriminate  the  ancestry ;  and  it  is  true 
that  in  many  such  cases  a  presumable  origin  in  some  bad 
inheritance  from  parents  or  others  further  removed,  may  be 
found.  However,  it  is  not  always  possible  in  such  cases  to 
justly  blame  ancestors,  and  theoretically  a  cause  is  sought  in 
some  congenital  defect  of  organization  of  the  nervous  system, 
the  cause  of  which  escapes  detection,  but  which  must  be  re- 
garded as  congenital,  because  indications  of  defective  mental 
development  were  apparent  in  the  earlier  years  of  life.  By  a 
natural  process  of  reasoning,  cases  of  insanity  that  present 
symptoms  like  those  seen  in  cases  of  hereditary  or  congenital 
defect,  are  placed  in  the  category  of  those  commonly  called 
degenerate,  even  when  a  history  of  heredity  is  wanting. 

Degeneracy  is  a  term  very  broadly  applied.  In  general 
it  means  a  condition  of  development,  mental  and  physical, 
that  leaves  the  individual  short  of  the  attainment  of  the  aver- 
age mental  and  physical  development  of  his  race.  In  many 
such  cases  a  lack  of  mental  balance  is  manifested,  which  in 
certain  cases  becomes  genius,,  in  others  imbecility  or  insanity. 
As  a  rule,  mental  and  physical  degeneracy  go  hand  in  hand ; 
that  is,  imperfections  of  physical  development  and  defects  of 
psychic  development  are  observed  in  the  same  individual. 
This  is  a  rule,  not  a  law.  Many  individuals  present  defects 
of  physical  development  without  any  sign  of  mental  degen- 


INTRODUCTION. 


eracy,  and  vice-versa :  the  presence  of  one  is  not  a  demon- 
stration of  the  other.  When  both  are  observed  in  one  person, 
they  can  be  regarded  as  correlated  to  the  general  defect  of 


organization  of  the  individual. 


LESSON  II. 
Historical  Review. 

Hospitals  or  asylums  for  the  insane  are  of  much  earlier 
origin  than  hospitals  for  bodily  disease,  unless  means  for 
the  treatment  and  care  of  patients  offered  by  the  followers  of 
Esculapius  are  regarded  as  hospitals.  Doubtless  there  were 
certain  material  means  for  the  protection  of  the  sick  in  the 
immediate  neighborhood  of  shrines  and  oracles. 

In  the  City  of  Lourdes,  in  France,  there  is  a  modern 
example  of  what  the  ancient  Grecian  shrine  for  the  treatment 
of  disease  must  have  been,  only  modified  in  some  details  for 
the  care  of  those  that  fail  to  obtain  relief.  There,  as  in 
ancient  times,  cures  are  the  result  of  supernatural  interven- 
tion ;  there,  those  that  are  concerned  with  the  thousands  that 
come  yearly  to  the  shrine  for  relief  or  cure,  have  become 
good  observers,  diagnosticians  in  a  sense;  as  were  the  dis- 
ciples of  Esculapius,  who  finally  made  possible  a  truly  scienti- 
fic observer — Hippocrates. 

With  him  the  study  of  diseases  of  the  brain  began ;  but 
we  have  far  to  go  before  insanity  is  generally  recognized  to 
be  a  result  of  disease. 

Mental  troubles  were  long  attributed  to  demoniacal  pos- 
session, and  cure  was  sought  by  means  of  exorcism,  etc.  Suc- 
cess in  a  certain  number  of  cases  following  such  treatment, 
was  a  certain  proof  that  those  that  were  not  sound  mentally, 

8 


HISTORICAL  REVIEW.  9 

were  objects  of  evil  influence  or  demoniacal  possession. 
Along  with  a  belief  in  demons  as  causes  of  insanity,  there 
was  also  the  notion  that  the  changes  of  the  moon  exerted 
an  influence  to  cause  mental  unsoundness.  Hence  come  the 
terms,  still  in  use  in  England  and  the  State  of  New  York, 
lunacy,  lunatic.  The  supposed  influence  of  the  planets  on 
human  destiny  is  perhaps  as  old  as  the  world  itself. 

The  dawn  and  development  of  Christianity  brought  no 
change  of  knowledge  of  abnormal  mental  conditions.  The 
evil  spirits  or  planetary  influences  of  earlier  times  were  still 
regarded  as  the  causes  of  mental  alienation,  though  their 
names  had  changed.  Still,  worse,  and  as  an  everlasting  proof 
of  the  frailty  of  the  mind  of  man,  was  the  belief  that  the  oper- 
ations of  demons  were  directed  by  individuals.  The  preva- 
lence of  a  belief  in  demonology  and  witchcraft  is  responsible 
for  the  torture  and  death  of  nine  millions  of  human  beings  in 
Christian  Europe  during  the  Middle  Ages. 

Disease,  owing  to  absence  of  knowledge  of  the  material 
aspect  of  life,  continued  to  be  regarded  as  a  supernatural 
matter  for  centuries;  the  dawn  of  the  light  of  science  was 
prolonged  through  ages,  and  even  now  it  would  be  hazard- 
ous to  attempt  to  prove  that  we  are  in  full  light  of  day. 

The  first  asylums  for  the  care  of  the  insane  as  subjects 
of  disease,  were  built  by  the  Turks.  In  Christian  countries 
insane  persons  were  looked  upon  as  criminals  and  treated 
accordingly  for  centuries  after  asylums  for  their  care  were 
established  in  lands  of  Moslem  faith.  This  is  not  surprising 
if  it  be  remembered  that  medical  science  was  highly  de- 
veloped among  the  Arabs  long  before  Galen  sought  to  inter- 
pret and  improve  the  observations  of  Hippocrates. 

Society  has  always  been  forced  to  take  some  care  of  the 
insane,  not  for  the  sake  of  such  unfortunate  beings,  but  for 


10  OUTLINES   OF   PSYCHIATRY. 

its  own  protection.  Ordinary  invalids  excite  pity,  but  are 
inoffensive  and  may  be  left  to  themselves;  insane  persons 
are  often  dangerous,  and  almost  always  so  considered.  Thus 
the  nature  of  insanity  forced  its  public  recognition  because 
of  its  tendency  to  disturb  society,  and  confinement  of  the 
insane  or  their  separation  from  society  was  a  necessity  rec- 
ognized from  the  first. 

During  the  Middle  Ages  the  insane  were  confined  in 
jails  or  dungeons,  and  there  made  to  endure  punishment  or 
wear  shackles  intended  for  criminals;  there  their  lot  was 
worse  than  that  of  common  malefactors,  owing  to  their  in- 
ability to  conform  to  discipline,  and  their  blind  raging 
against  mechanical  restraint.  Often  chained  in  a  dark  cell 
they  were  left  to  wallow  in  accumulations  of  filth  during 
months  and  years,  starving  or  living  on  food  passed  to  them 
as  to  a  wild  beast. 

During  the  dark  ages  of  religious  fanaticism  the  millions 
of  human  beings  sacrificed  to  appease  popular  superstition 
were  not  all  insane,  as  might  at  first  view  be  concluded; 
rather  the  insane  of  certain  categories  were  the  incitors  of 
persecution  of  sane  and  inoffensive  persons.  The  hysterical 
and  those  suffering  with  delusions  of  persecution  were  most 
frequently  the  accusers  of  innocent  persons,  who  thus  fell 
victims  to  popular  ignorance  and  fanaticism.  For  a  universal 
belief  in  demons  made  the  populace  ready  to  accept  as  truth 
the  delusional  accusations  of  anyone  against  anybody,  if  the 
accusations  were  in  harmony  with  the  prevalent  superstition. 
Doubtless,  as  was  the  case  in  Salem,  certain  insane  or  pe- 
culiar persons  often  became  the  object  of  accusation,  and 
thus  the  victims  of  popular  hatred. 

Insane  delusions  and  ideas  are  always  in  harmony  with 
popular  beliefs  or  prevalent  notions.     To-day  the  remnant 


HISTORICAL  REVIEW.  11 

of  early  insane  ideas  of  demonology  is  seen  in  the  religious 
delusions  of  the  insane,  which  still  meet  with  acceptance  by 
persons  religious  and  ignorant;  but  insane  ideas  of  persecu- 
tion now  most  frequently  have  to  do  with  electricity — the 
telephone,  batteries,  etc.,  and  we  shall  soon  observe  patients 
whose  ideas  are  concerned  with  the  operation  of  X-rays 
and  wireless  telegraphy.  However,  the  enemy  remains  a 
person  or  persons  operating  these  means  of  persecution ;  just 
as  formerly  the  demons  were  directed  in  their  malevolence 
by  some  person  or  persons. 

Improvement  in  the  knowledge  of  insanity  and  in  its 
treatment  did  not  keep  pace  with  the  progress  of  medical 
science  in  general,  because  the  mind  and  its  manifestations 
remained  a  matter  of  pure  speculation  almost  up  to  our  own 
da}'. 

Late  in  the  eighteenth  century  more  humane  treatment 
was  afforded  the  unfortunate  victim  of  insanity;  the  notion 
that  insanity  is  the  result  of  disease  began  to  penetrate  the 
mind  of  the  masses,  and  separate  hospitals  for  the  insane  were 
established  here  and  there  in  Europe.  But  such  asylums  re- 
mained the  object  of  popular  fear  and  abhorrence.  The  Beth- 
lehem Asylum  in  London  gave  rise  to  the  popular  use  of  the 
word  "Bedlam,"  that  will  remain  as  an  index  of  popular 
estimation  of  what  a  congregation  of  lunatics  must  be. 

The  most  remarkable  amelioration  of  the  treatment  of  the 
insane  is  due  to  Pinel,  who,  as  physician  at  Bicetre 
and  the  Salpetriere,  hospitals  for  the  insane  in  Paris,  late 
in  the  eighteenth  century,  inaugurated  the  abandonment  of 
the  grosser  forms  of  mechanical  restraint :  he  unlocked  the 
shackles  and  chains  that  for  centuries  had  been  considered 
an  indispensable  part  of  the  care  of  the  insane.  In  England, 
some  years  earlier  St.  Luke's  Hospital,  for  the  care  of  the 


12  OUTLINES  OF   PSYCHIATRY. 

insane,  had  been  established  in  London ;  and  at  abont  the 
same  epoch,  Tuke  established,  with  the  aid  of  the  Society 
of  Friends,  the  York  Retreat,  where  enlightened  and  humane 
methods  were  employed,  and  whence  they  spread  throughout 
Great  Britain,  and  to  the  United  States.  In  other  countries 
like  changes  for  the  better  were  made.' 

The  development  of  the  system  of  colonization  of  insane 
patients  in  Europe  and  the  United  States  is  traceable  to  a 
very  old  system  originated  in  Belgium,  where,  at  Gheel,  a 
colony  of  insane  persons  has  existed  for  many  centuries. 

At  the  present  time  the  methods  for  the  care  and  treat- 
ment of  the  insane  in  vogue  in  civilized  countries,  are  in 
general  uniform,  though  there  are  differences  due  to  exi- 
gencies of  revenue  or  other  economical  circumstances.  The 
object — cure  and  amelioration — is  sought  through  means  the 
most  humane,  with  the  largest  degree  of  personal  liberty, 
healthy  employment  and  amusement,  and  the  application  of 
all  the  special  therapeutic  measures  known  to  medical  science. 

Every  state  has  hospitals  for  the  insane,  and  laws  enacted 
for  their  protection,  though  unfortunately  state  hospitals  are 
not  always  administered  with  reference  to  what  science  might 
do  for  the  patients.  In  some  states,  for  political  or  economic 
reasons,  the  county-house  is  still  used  as  a  place  of  detention 
for  the  mentally  unsound;  and  naturally  the  medical  atten- 
tion given  under  such  circumstances  is  not  all  that  is  desira- 
ble, even  if  abuses  were  not  the  rule  in  such  places. 
However,  the  time  is  not  far  distant  when  all  such  imper- 
fections will  cease  to  exist.  All  state  institutions  for  the 
mentally  defective  will  be  administered  by  competent  men 
of  scientific  training,  and  all  such  hospitals  will  thus  add  to 
the  sum  of  progress  in  scientific  knowledge  and  enlightened 
treatment  of  insanity. 


HISTORICAL  REVIEW.  13 

The  history  of  psychiatry  as  a  science  can  be  resumed  in 
a  review  of  the  work  of  observers  recorded  during  the  last 
one  hundred  years. 

Griesinger's  work  may  be  taken  as  representing  the  be- 
ginning of  modern  psychiatry  in  Germany;  and  the  science 
has  been  most  highly  developed  by  many  later  workers  both 
there  and  in  Austria.  Schiile,  Krafft-Ebing,  and  Krapelin, 
among  many  others,  may  be  mentioned  as  observers  that 
have  exerted  a  great  influence  on  the  science. 

In  France  psychiatry  had  able  workers  in  Pinel,  Esquirol, 
Le  Grande  du  Saulle  and  Morel ;  the  latter  is  the  originator  of 
the  theory  of  degeneracy  that  has  exercised  so  great  an  in- 
fluence on  modern  psychiatry,  especially  in  Germany,  and 
which  has  been  carried  to  an  extreme  in  the  theories  of  Lom- 
broso,  of  Turin.  Modern  French  psychiatry  has  able  expon- 
ents in  Magnan,  Bourneville,  Pierre  Janet,  Toulouse,  and 
Regis,  who  were  preceded  by  such  noted  scientists  as  Cal- 
miel,  Baillarger,  and  Falret.  But  the  early  French  school  has 
exercised  a  much  more  important  influence  on  psychiatry 
than  its  later  exponents.  We  owe  the  recognition  of  de- 
mentia paralytica  (paresis)  to  French  observers,  as  well  as 
the  earliest  recognition  of  its  cause. 

In  Great  Britain  the  progress  of  psychiatry  is  marked  by 
many  illustrious  names,  beginning  with  the  Tukes  and  fol- 
lowed by  Conolly,  Maudsley,  Clouston,  Ireland,  Savage, 
Lewis,  and  many  others.  The  modern  system  of  non- 
restraint  is  due  to  Conolly.  The  asylums  of  Scotland  repre- 
sent, perhaps,  the  highest  development  of  the  institution  for 
the  insane. 

The  progress  of  psychiatry  in  our  land  was  naturally 
early  marked  by  the  influence  of  English  ideas,  to  which  we 
owe  much,  especially  in  humanitarian  methods.     In  recent 


14  OUTLINES   OF   PSYCHIATRY. 

years  we  have  been  guided  almost  entirely  by  the  German 
school,  until  we  have  taken  our  place  as  original  workers  in 
the  field.  Now  in  all  civilized  countries  the  methods  of  care 
and  study  of  the  insane  are  practically  the  same :  originated 
by  the  English  and  French  schools,  and  developed  most  con- 
spicuously by  the  German  school. 


LESSON  III. 
Mental  Physiology. 


Mind  is  a  term  that  covers  all  that  one  experiences  as  an 
individual :  sensations,  thoughts,  and  acts  that  are  recognized 
as  taking  place  or  having  origin  in  oneself.  Mind,  then,  as  it 
can  be  known,  is  a  subjective  experience  which  can  be  exam- 
ined objectively  only  through  the  secondary  and  material 
results  of  its  activity.  What  a  person  feels,  thinks  or  desires 
can  only  be  known  to  another  through  movements,  acts,  etc. 
One  learns  to  know  what  is  passing  in  the  mind  of  another 
by  his  acts:  expression  of  face;  movements  of  members; 
inarticulate  and  articulate  sounds.  Mind  can  only  be  recog- 
nized as  objectively  existent  or  studied  objectively  by  means 
of  its  material  modes  of  revelation.  Action  (movement,  con- 
duct) is  to  mind  what  a  thermometer  is  to  temperature:  a 
measure. 

Psychology  is  a  science  made  up  of  the  results  of  subjec- 
tive and  objective  study:  subjective  self-observations  and  in- 
terpretations of  the  acts  of  others. 

It  has  been  established  that  the  mind  has  its  seat  in  the 
cortex  of  the  brain,  though  general  recognition  of  this  fact 
does  not  yet  date  back  one  hundred  years. 

Sensation  is  an  absolute  pre-requisite  for  the  develop- 
ment of  mind.  Mind  is  in  reality  a  phenomenon  interposed 
between  what  is  known  in  biology  as  irritability  and  con- 

15 


16  OUTLINES   OF   PSYCHIATRY. 

tractility  as  displayed  by  the  lowest  forms  of  organized  living 
matter.  Irritability  in  the  amoeba  may  be  regarded  as 
synonymous  with  sensibility.  Sensitiveness  to  mechanical  in- 
fluence— contact — is  the  starting-point  of  movement  of  con- 
tractile bodies.  Such  movements  are  primarily  those  of  at- 
traction. Thus,  the  amoeba  seeks  to  assimilate  all  that  comes 
in  contact  with  it,  and  such  matter  as  is  capable  of  becoming 
a  part  of  the  amoeba  is  incorporated;  while  such  as  is,  for 
physical  reasons,  unsuitable  is  abandoned  mechanically  as  a 
result  of  the  constant  movements  of  attraction  excited  by 
simultaneous  or  succeeding  mechanical  stimuli.  But  certain 
materials  by  contact  are  capable  of  exciting  movements  of 
repulsion;  and  thus  is  established  the  organic  possibility  of 
choice,  which  in  its  lowest  form  is  apparently  determined  by 
material  conditions,  but  which  in  its  essence  must  depend 
on  the  vital  qualities  of  the  living  organism  displaying  the 
phenomenon. 

In  the  lowest  forms  of  animal  life  are  observed  sensibility, 
movements,  choice ;  and  these  attributes  may  be  easily  recog- 
nized as  the  same,  essentially,  as  those  observed  in  thinking 
beings :  the  feelings  are  the  ultimate  development  of  sensi- 
bility ;  the  will  is  the  final  development  of  mechanical  choice 
always  expressed  in  movements ;  the  intellect  is  a  term  that 
covers  all  subjective  operations  that  take  place  between  sensa- 
tion and  voluntary  action ;  it  represents  in  the  lower  orders 
the  organic  conditions  that  give  rise  to  movements  of  attrac- 
tion or  repulsion. 

Mind  depends  for  its  origin  and  development  upon  the 
senses  (various  modes  of  sensibility).  An  organism  devoid 
of  means  of  communication  with  the  external  world,  dies, 
no  matter  how  perfect  its  internal  organization  for  all  other 
functions.     In  the  development  of  human  beings,  one  sense, 


MENTAL  PHYSIOLOGY.  17 

though  it  be  the  lowest,  may  suffice  for  the  development  of 
mind,  if  the  individual  be  aided  and  the  one  sense  be  culti- 
vated. Witness  the  case  of  Helen  Keller,  who  developed 
mentally  through  the  single  sense  of  touch,  the  lowest  of 
those  possessed  by  the  higher  orders  of  animals.  However, 
all  the  senses  are  simply  modifications  of  sensibility  to  con- 
tact. Sight  is  the  appreciation  of  contact  of  light ;  hearing  is 
due  to  contact  of  air  in  vibration ;  taste  and  smell  are  other 
modes  of  interpretation  of  contact : — all  the  senses  are  inter- 
pretations of  modes  of  motion  made  possible  by  the  develop- 
ment of  special  organs. 

Special  organs  for  the  various  senses  require  special 
nerve-centers  for  the  registration  of  their  activities.  The 
cortex  of  the  brain  is  the  seat  of  these  centers,  the  autonomy 
of  which  is  as  distinct  as  that  of  the  sense-organs  them- 
selves. Destruction  of  a  cortical  sensory  center  as  effectual- 
ly destroys  that  sense  as  destruction  of  the  corresponding 
sense  organ;  in  fact,  more  surely,  for  loss  of  sight  from 
lesion  of  the  eyes  does  not  destroy  visual  memory, — the  rec- 
ord of  previous  visual  images ;  while  blindness  due  to  corti- 
cal lesion  causes  loss  of  acquired  visual  memories  and  loss 
of  power  to  acquire  more. 

This  is  true  of  every  sense;  for  there  is  more  or  less 
distinct  localization  in  the  cortex  of  each  sense.  The  sense 
of  sight  has  its  seat  in  the  occipital  lobes  in  the  neighborhood 
of  the  calcarine  fissure;  the  sense  of  hearing  has  its  centers 
in  the  temporal  lobes ;  the  centers  for  taste  and  smell  lie  prob- 
ably in  the  falciform  lobe;  the  centers  for  touch  are  identical 
in  the  main  with  the  motor  centers  which  occupy  the  con- 
volutions in  the  immediate  neighborhood  of  the  fissure  of 
Rolando. 

Besides  these  primary  centers,  there  are  others  destined 


18  OUTLINES  OF    PSYCHIATRY. 

to  subserve  certain  qualities  of  one  sense,  or  certain  combi- 
nations of  two  or  more  senses.  Thus  the  left  angular  gyrus 
is  the  center  for  recognition  of  written  language;  the  left 
superior  temporal  convolution  contains  the  center  for  recog- 
nition of  speech.  Destruction  of  these  higher  mental  centers 
of  language  in  no  way  entails  blindness  or  deafness,  but 
causes  loss  of  power  to  understand  written  and  spoken  lan- 
guage. 

There  are  other  so-called  senses,  like  the  muscle-sense 
and  stereognostic  sense,  which  are  the  result  of  combinations 
of  several  forms  of  sensibility  derived  from  various  parts  of 
the  body.  Analysis  of  the  stereognostic  sense  or  of  the 
faculty  of  language  shows  how  any  single  sense  is  of  small 
account  as  a  factor  in  the  development  of  the  mind ;  how 
mental  development  depends  upon  interrelated  development 
of  many  senses. 

As  an  illustration  of  the  complexity  of  a  given  faculty, 
that  of  speech,  which  is  at  the  very  foundation  of  the  human 
mind,  may  be  taken  as  an  example  of  the  association  of  the 
activity  of  the  various  senses.  Speech  is  practically  impossi- 
ble without  hearing,  and  absolutely  so  if  deafness  and  blind- 
ness co-exist.  Reference  is  understood  to  be  to  congenital 
defect.  Acquirement  of  speech  is  fundamentally  dependent 
upon  the  auditory  appreciation  of  sounds  and  the  reproduc- 
tion of  them  by  imitation.  A  later  or  ultimate  development 
of  language  is  the  addition  of  symbols  or  signs  appreciable 
to  sight  as  representatives  of  sounds, — written  language,  the 
highest  product  of  the  human  mind.  Thus  language  in  its 
complete  normal  development  is  an  association  of  hearing, 
movement,  and  sight,  for  which  there  are  three  distinct  but 
associated  centers  in  the  cerebral  cortex :  the  auditory  center 
for  speech ;  the  motor  center  for  speech ;  and  the  visual  center 


MENTAL  PHYSIOLOGY.  19 

for  written  signs  of  speech-sounds.  All  these  centers  lie  in 
the  left  hemisphere  of  the  brain  (in  right-handed  persons), 
and  are  intimately  associated  by  nervous  interconnections. 
Dejerine  calls  these  three  centers,  found  in  the  inferior  fron- 
tal, the  superior  temporal,  and  the  angular  gyrus,  with  their 
fibres  of  association,  the  "zone  of  language." 

No  clearer  illustration  of  the  important  relation  of  lan- 
guage to  intellect  is  offered  than  that  presented  in  the  various 
forms  of  disturbance  of  speech  due  to  various  lesions  of  the 
"zone  of  language." 

1.  Suppose  an  adult  has  become  unable  to  use  the  or- 
gans concerned  in  articulation :  articulate  language  is  impos- 
sible, but  the  subject  is  able  to  think  and  communicate  his 
ideas  by  means  of  signs,  written  or  indicated  by  movements ; 
he  understands  spoken  or  written  language.  It  is  of  no  im- 
portance what  causes  the  incapacity  as  far  as  internal  lan- 
guage— thought — is  concerned,  if  the  cause  lie  outside  of  the 
cerebral  cortex  and  the  subcortical  paths  of  association  of  the 
centers  of  the  zone  of  language.  A  lesion  of  the  larynx,  of 
the  medulla,  of  the  motor  fibres  below  the  centers  in  the  lower 
third  of  the  Rolandic  area,  is  without  effect,  beyond  paralysis 
of  articulation ;  the  affected  person  understands  and  com- 
municates his  ideas  as  before,  though  forced  to  use  other  ave- 
nues exclusively — writing  and  motor  signs.  If  he  be  unable 
to  write  with  his  right  hand  (paralysis),  he  uses  his  left;  and 
if  both  hands  be  useless  he  employs  his  feet,  after  a  bit  of 
practice. 

2.  With  a  lesion  or  lesions  affecting  the  cortical  zone  of 
language,  the  result  is  quite  different.  If  the  motor  center 
of  speech  be  destroyed,  the  individual  is  no  longer  able  to 
express  himself  in  words;  he  cannot  think  clearly  in  words, 
therefore  he  can  express  himself  in  no  way  perfectly;  he 


20  OUTLINES   OF   PSYCHIATRY. 

cannot  write  or  read  perfectly,  or  understand  perfectly  spoken 
language.  A  lesion  of  the  auditory  center  of  language  entails 
likewise  grave  disturbance  of  thought  (internal  speech)  ; 
for  the  individual  can  no  longer  understand  spoken  words, 
and  cannot  control  his  own  words  through  the  sense  of  hear- 
ing; his  attempts  to  speak  are  incomprehensible  jargon. 
Similarly,  lesion  of  the  visual  center  of  language  causes  dis- 
turbance of  internal  language  in  one  educated  to  read  literal 
signs  and  to  think  in  them ;  for  he  can  no  longer  write  or 
read,  and  the  normal  equilibrium  established  by  the  co-ordi- 
nation of  the  motor,  auditory,  and  visual  centers  of  language, 
is  destroyed.  The  memory  of  much  that  has  been  acquired 
through  written  signs  is  obliterated,  and  a  large  part 
of  the  mental  store  is  lost. 

The  STEREOGNOSTic  sense  also  illustrates  the  manner  in 
which  various  senses  or  sensations  serve  to  develop  ideas. 
We  are  able  to  recognize,  without  the  sense  of  sight,  vari- 
ous objects  or  their  physical  qualities  if  allowed  to  handle 
them.  Many  qualities  of  sensory  experience  may  be  neces- 
sary for  such  recognition :  form,  nature  of  surface,  tempera- 
ture, weight,  size.  Certain  brain  lesions  may  entirely  de- 
stroy this  so-called  stereognostic  sense,  which  depends  upon 
the  various  qualities  of  the  sense  of  control,  motion,  muscu- 
lar force,  joint-movement,  and  space  relation  of  the  cutane- 
ous surfaces. 

At  the  base  of  all  mental  development  lies  what  we  call 
memory.  Popularly  speaking,  memory  is  the  ability  to  re- 
call at  will  this  or  that  mental  image  or  idea ;  to  represent 
in  thought  that  which  has  been  seen,  etc.  However,  volun- 
tary memory  is  a  faculty  that  depends  very  largely  upon 
two  senses  :  sight  and  hearing.  We  may  evoke  a  face,  a  form, 
a  scene;  and  we  may  feel  again  the  emotions  experienced 


MENTAL  PHYSIOLOGY.  21 

under  certain  circumstances.  The  words  of  another,  spoken 
or  written,  may  be  recalled  with  perfection  of  reproduction. 
But  in  general  it  may  be  said  that  the  perfection  of  ideational 
reproduction  depends  on  the  degree  or  intensity  of  emotional 
activity  that  primarily  accompanied  the  experience.  Thus 
the  early  experiences  of  childhood  and  youth,  accompanied 
by  the  most  intense,  unique,  and  isolated  emotions,  are  those 
longest  and  most  accurately  evocable  at  will.  Facts  early 
learned  by  repetition  are  also  among  those  most  easily  re- 
called; in  part  becaust  of  early  impressionability,  in  part 
because  of  later  constant  repetition  in  experience.  However, 
this  psychologic  aspect  of  voluntary  memory,  of  great  im- 
portance for  the  intellectual  status  of  the  individual,  is  only 
a  higher  development  of  involuntary  organic  memory. 

Voluntary  memory  is  essentially  a  reproduction  of  ex- 
perience through  emotion  and  the  senses  of  sight  and  hear- 
ing; organic  memory  (perceptual)  is  dependent  on  inner  un- 
conscious registration  of  experiences  which  are  not  neces- 
sarily reproducible  voluntarily.  For  example,  we  may  be  able 
to  recall  an  experience  of  having  great  physical  pain,  as  from 
a  burn :  in  this  we  never  feel  again  the  pain,  we  merely  say 
that  we  had  a  pain,  and  recall  the  circumstances  attending  the 
pain.  Our  inability  to  reproduce  voluntarily  this  pain  once 
experienced  is  parallel  with  our  unconsciousness  of  the  ele- 
ments of  organic  memory.  Voluntary  memory  reproduces  an 
experience  as  a  whole ;  organic  memory  is  the  unconscious 
basis  on  which  the  experience  as  a  whole  rests.  To  illustrate 
this  fact,  take  any  object,  as  an  orange :  it  presents  itself  to 
consciousness  through  various  senses — sight,  smell,  touch, 
taste — and  it  is  recognized  as  an  orange  without  the  con- 
scious intervention  of  any  of  the  elements  of  sense-impres- 
sions that  it  evokes ;  it  is  recognized  because  other  oranges 


22  OUTLINES  OF   PSYCHIATRY. 

have  been  seen,  smelt,  and  felt.  One  might  have  seen  many 
oranges  and  never  voluntarily  evoke  one  in  memory;  but 
seen  again  an  orange  would  be  recognized,  by  reason  of  or- 
ganic memory  (perceptual).  Again,  to  make  clear  this  dif- 
ference ;  a  person  once  known  is  forgotten,  but  an  effort  is 
made  later  to  recall  face,  form,  and  name,  in  vain ;  yet  seen 
again  the  person  is  immediately  recognized.  This  is  enough 
to  show  the  difference  between  voluntary  and  organic  mem- 
ory, and  to  emphasize  organic  or  unconscious  memory  as  the 
basis  of  what  is  known  as  memory.  In  fact  the  registry  of 
sense-impressions  and  the  unconscious  association  of  them 
form  the  basis  upon  which  elaborate  mental  development  de- 
pends. 


LESSON  IV. 
Elementary  Psychology. 

Psychology  is  the  science  of  normal  mental  activity. 

Since  we  are  not  familiar  with  the  physical  conditions 
that  underlie  mental  phenomena,  we  are  forced  to  study 
mind  from  its  manner  and  qualities  of  manifestation,  and 
thus  we  must  constantly  employ  the  methods  and  terms  of 
psychology. 

The  first  psychologic  element  is  sensation.  An  orange 
presents  itself  to  us  through  various  avenues  of  sensibility, 
and  the  various  sensations  of  which  it  is  the  external  cause 
lead  us  to  invest  it  with  various  physical  qualities — form, 
size,  weight,  color,  odor,  etc.  The  combination  of  the  vari- 
ous sensations  obtained  from  an  orange  with  the  consequent 
investment  of  it  with  certain  qualities  that  distinguish  it 
from  other  objects  leaves  in  the  mind  a  picture,  or  mental 
image,  which  permits  recognition  of  another  orange.  The 
recognition  of  the  orange  as  an  object  having  certain  cl;s- 
tinguishing  qualities  is  perception. 

The  process  of  perception  is  always  very  complicated, 
for  many  elementary  sensations  are  necessary  for  the  for- 
mation of  the  simplest  percept, — the  mental  image. 

The  reproduction  in  mind  of  the  result  of  perception, — 
the  mental  image, — is  called  memory. 


24  OUTLINES  OF   PSYCHIATRY. 

The  process  by  which  mental  images,  or  ideas,  are  com- 
bined is  called  thinking,  or  ideation. 

In  the  act  of  thinking  the  combination  or  association  of 
ideas  takes  place  according  to  certain  laws :  similarity,  con- 
trast, co-existence,  succession,  cause  and  effect. 

Similarity  as  a  factor  in  thought  is  illustrated  when  an 
idea  excited  by  perception  of  an  object  is  followed  by  the 
awakening  in  consciousness  of  the  image  of  some  similar 
object. 

Contrast  may  be  understood  readily  if  it  is  remembered 
how  smoothness  of  necessity  can  only  be  known  through 
experience  of  roughness. 

Co-Existlnce  :  when  one  mental  image  comes  into  con- 
sciousness others  that  were  developed  at  the  same  time  are 
re-awakened. 

Succession,  which  is  understood  to  apply  to  both  time 
and  space,  plays  a  great  role  in  the  association  of  ideas ;  the 
re-awakening  of  one  idea  is  followed  by  that  of  others  origi- 
nally developed  before  or  after  it. 

Cause  and  eefect.  Our  notion  of  relation  of  cause 
and  effect  is  fundamentally  dependent  upon  succession  of 
events  in  time.  This  notion  of  relation  once  developed,  it 
becomes  a  source  of  association  of  ideas :  a  cause  calls  up  its 
effect;  the  idea  of  a  result  known  to  depend  on  a  certain 
cause  suggests  the  idea  of  that  cause. 

Ideas  once  developed  become  elements  of  thought,  and 
all  the  elementary  operations  of  sensations  and  perceptions 
that  were  needed  for  their  formation  are  erased  from  them. 
The  highest  development  of  ideas  is  in  their  association  with 
words,  which  stand  for  ideas. 

Judgment  is  a  term  that  covers  the  result  of  thinking 


ELEMENTARY   PSYCHOLOGY.  25 

that  leads  to  some  conclusion,  and  is  thus  the  result  of  reas- 
oning. 

Memory,  organic  and  voluntary,  is  absolutely  necessary 
to  any  process  of  thought. 

Percepts  and  ideas  have  another  aspect :  they  are  ac- 
companied by  feelings. 

Feelings  have  two  qualities,  pleasureable  and  painful, 
but  there  may  be  a  state  that  partakes  of  neither  of  these 
qualities,  which  may  be  called  indifference. 

Two  orders  of  feelings  may  be  distinguished.  The 
lower  order  comprises  the  feelings  that  accompany  sense- 
perceptions,  objective  and  subjective  (sensual)  ;  of  the 
higher  order  are  the  feelings  developed  as  a  result  of  intel- 
lectual development  and  which  are  more  or  less  of  a  moral 
nature :  ethical  sensibility,  religious  feeling,  aesthetic  feel- 
ing, etc. 

A  person  is  conscious  when  aware  of  his  own  existence; 
this  mental  state  is  called  consciousness,  and  psychologically 
it  may  be  defined  as  the  sum  of  all  the  percepts,  ideas,  and 
feelings  present  in  the  mind  at  a  given  moment. 

Sele-consciousness,  or  knowledge  of  one's  own  ex- 
istence as  a  unit  distinguished  from  all  else  and  knowledge 
of  the  activities  of  one's  own  mind,  is  the  essential  element 
of  individual  existence,  and  with  it  is  developed  the  idea  of 
the  Ego.  The  fully  developed  Ego,  owing  to  its  seeming 
ability  to  act  freely  and  independently,  and  from  a  motive  of 
choice,  is  said  to  possess  a  will. 

The  will  is  not  a  primary  mental  function  comparable 
with  those  already  discussed.  The  will  is  an  idea  born  of 
other  ideas,  which  engenders  other  ideas,  and  its  special  char- 
acter is  due  to  its  greater  intensity  or  accentuation.  It  leads 
to  acts  either  psycho-physical  or  purely  psychic.     We  may 


26  OUTLINES  OF   PSYCHIATRY. 

will  to  perform  an  act  in  which  there  is  mental  action  and 
physical  movement;  we  may  direct  our  thought  at  will 
without  any  obvious  physical  revelation  of  the  subjective 
mental  act. 

What  we  subjectively  experience  and  understand  as  will, 
is,  to  illustrate  the  foregoing  definition,  the  final  develop- 
ment of  the  relationship  between  the  ideas  present  in  con- 
sciousness at  a  given  time,  modified  by  habit  of  mental  re- 
action to  ideas  and  feelings  of  certain  categories. 

Certain  external  and  internal  stimuli  may  give  rise  to  an 
impulsion  to  a  certain  act,  and  ultimately  find  expression 
in  that  act :  the  mental  process  that  lies  between  the  ideas 
which  incite  to  an  act  and  conscious  choice  to  perform  it, 
is  called  reflection.  If  reflection  be  wanting,  there  can  be 
no  question  of  will  in  the  act;  it  is  an  involuntary  impulse, 
or  a  psychic  reflex  act. 

The  simplest  form  of  response  to  an  external  stimulus 
is  that  known  as  reflex  movement.  Association  of  several 
reflex  centers  may  suffice  to  form  the  basis  of  complicated 
reflex  movements,  which  on  the  surface  do  not  differ  from  a 
voluntary  act.  These  complicated  reflex  movements  may 
be  called  automatic  acts,  to  distinguish  them  from  simple 
reflex  action ;  they  need  have  no  relation  to  consciousness, 
or  consciousness  may  be  entirely  occupied  with  them. 

Certain  reflexes  of  higher  organization  are  developed 
before  mind,  such  as  the  instinctive  movements  of  the  infant ; 
so  that  the  organism  lives  for  a  long  time  aided  only  by  the 
mechanical  (congenital)  arrangement  of  nerve  centers  to 
respond  in  certain  ways  to  certain  impressions — hunger, 
thirsty  etc. 

Mind  with  its  seeming  power  of  control  of  reflex,  auto- 


ELEMENTARY   PSYCHOLOGY.  27 

matic,  and  instinctive  action,  is  thus  only  the  highest  form  of 
development  of  nervous  activity. 

The  play  of  ideas  in  consciousness  determines  a  mental 
faculty  known  as  attention,  which  we  are  accustomed  to 
regard  as  an  aspect  of  the  will. 

Psychologically,  attention  may  be  defined  as  the  mental 
state  of  pre-occupation  with  certain  percepts  or  ideas  to  the 
exclusion  of  others. 

Ordinarily,  within  certain  limits  we  are  able  to  deter- 
mine what  shall  occupy  attention,  to  direct  our  thoughts  here 
or  there  at  will.  This  is  possible  only  when  the  force  or 
intensity  of  higher  ideas  and  feelings  exceeds  that  of  lower 
sense-perceptions  with  their  emotional  sensory  coloring. 
For  example,  the  pain  of  a  severe  physical  injury  immedi- 
ately overcomes  all  effort  to  attend  to  anything  else.  Be- 
tween such  a  condition  of  forced  attention  and  the  ordinary 
voluntary  play  of  attention  there  are  infinite  degrees  of  com- 
bination of  the  higher  and  lower  determining  factors. 

The  most  important  determining  factor  in  mental  activ- 
ity is  the  feelings  (emotions).  Under  certain  circumstances 
the  higher  emotional  states  may  exclude  all  lower  sensory 
feelings  from  consciousness. 

We  have  to  deal  with  three  aspects  of  mind :  the  feelings 
(emotions),  the  intellect  (ideas),  and  the  will  (conduct); 
and  in  the  study  of  the  elementary  mental  anomalies  of  in- 
sanity we  must  consider  them  with  relation  to  this  division. 

Insanity  always  shows  disorder  in  these  three  aspects  of 
mind,  predominating  perhaps  in  one,  but  always  with  dis- 
turbance in  the  others. 


LESSON  V. 
Elementary  Anomalies  oe  the  Mind.    (1) 

The  anomalies  oe  sensation  consist  of  three :  hyper- 
esthesia, paresthesia,  and  anesthesia  (various  degrees  of 
hypesthesia). 

Disturbances  of  sensation  may  be  due  to  disease  of  the 
sensory  tract,  end-organ,  or  cortical  center.  In  general  they 
have  the  significance  of  physical  disease  until  the  mind  gives 
them  an  erroneous  intei-pretation ;  then  they  become  an  im- 
portant source  of  mental  disturbance. 

It  is  evident  that  anesthesia  due  to  disease  of  peripheral 
nerves  or  sense-organs  is  not  in  itself  sufficient  to  cause 
mental  disturbance;  anesthesia  is  observed  daily  in  persons 
normal  mentally  who  interpret  the  anomaly  as  a  fact 
which  disturbs  in  no  way  the  general  mental  activities.  On 
the  other  hand,  when  there  is  disturbance  of  the  mind  an 
anomaly  of  sensation  may  be  interpreted  mentally  in  some 
fantastic  way  and  become  the  foundation  of  a  persistent 
false  idea.  Ear-noises,  to  the  disturbed  mind,  may  take  the 
form  of  language,  and  be  accepted  as  actual  speech. 


1  A.    Anomalies  of  the  intellect. 


1.  Of  sensation. 

2.  Of  perception. 

3.  Of  thought. 

4.  Of  memory. 


B.  Anomalies  of  the  feelings. 

C.  Anomalies  of  the  will — conduct. 

28 


ELEMENTARY  ANOMALIES  OF  THE   MIND.  29 

In  the  study  of  special  forms  of  insanity  there  will  be 
abundant  opportunity  to  explain  the  part  played  by  elemen- 
tary anomalies  of  sensation  in  the  origin  and  maintenance  of 
certain  mental  symptoms. 

Perception  is  the  recognition  of  an  external  object  by 
means  of  one  or  more  of  the  senses,  and  presents  anomalies 
in  the  form  of  hallucinations,  illusions,  etc. 

Hallucination.  Normally,  while  awake  we  are  more 
or  less  distinctly  conscious  of  our  surroundings,  and  we  ac- 
cept the  evidence  of  our  senses  without  question.  A  sense- 
perception  of  something  seemingly  external  that  has  no 
material  existence  is  an  hallucination.  An  hallucination 
must  have  its  cause  in  the  nervous  system,  and  presumes  the 
pre-existence  in  cortical  centers  of  images  of  percepts.  Psy- 
chologically, hallucination  may  be  defined  as  the  re-awaken- 
ing in  consciousness  of  an  image  (perceptual)  with  such  in- 
tensity that  it  is  projected  into  space.  It  is  presumed  by  cer- 
tain observers  that  with  the  central  re-awakening  of  the 
image  there  is  a  simultaneous  eccentric  excitation  of  the  re- 
lated peripheral  sense-organ  which  lends  to  the  image  further 
subjective  attributes  of  reality. 

Illusion  is  another  variety  of  false  sense-perception, 
allied  to  hallucination,  though  in  general  of  less  pathologic 
significance.  An  illusion  is  a  false  interpretation  of  the  im- 
pression made  on  the  sensory  centers  by  something  external 
to  them.  Normally  it  is  of  common  occurrence:  we  daily 
misinterpret  sights  and  sounds,  and  arrive  at  the  truth  only 
after  controlling  the  first  evidence  by  other  evidence.  We 
turn  in  the  street  at  the  sound  of  our  name  to  find  that  the 
sound  was  not  our  name,  but  something  that  sounded  like  it. 
The  maneuvers  of  the  "magician"  are  all  based  upon  the  ten- 
dency of  our  senses  to  make  illusional  errors. 


30  OUTLINES   OF   PSYCHIATRY. 

In  mental  pathology  it  is  frequently  difficult  and  often 
impossible  to  strictly  differentiate  between  hallucination  and 
illusion ;  and  it  is  of  small  practical  importance  in  the  insane 
condition,  because  as  symptoms  of  insanity  they  have  prac- 
tically the  same  significance;  for  this  reason  hallucination  is 
the  term  frequently  used  to  indicate  both  in  the  insane. 

Hallucination  as  such  is  not  a  sign  of  insanity  though 
in  its  narrow  sense  it  is  probably  always  pathologic. 

Hallucination  as  a  symptom  of  insanity  is  invested  with 
a  mental  attribute  which  it  does  not  obtain  in  persons  men- 
tally sound:  it  is  accepted  as  real  (objective).  Belief  in  the 
objective  reality  of  a  temporary  vision  (hallucination),  to  be 
evidence  of  an  insane  state  of  mind,  must  be  the  result  of 
disease  and  not  the  result  of  education  or  training.  Persons 
taught  to  believe  in  ghosts  sometimes  see  them  and  after- 
wards believe  they  saw  something  objective:  they  are  the 
deluded  victims  of  ignorance,  not  of  disease,  and  therefore 
not  insane. 

Hallucinations  of  sight  occur  in  all  degrees  of  complex- 
ity from  the  perception  of  simple  sparks  to  the  most  com- 
plicated visions. 

Auditory  hallucination  may  also  be  very  simple  or  very 
complex.  Hallucinations  of  hearing  may  be  in  the  form  of 
noises,  words,  or  sentences.  Hallucinations  of  hearing  some- 
times lead  to  belief  that  the  thoughts  are  stolen ;  the  patient 
hears  his  own  thoughts,  and  he  may  think  that  another  de- 
vines  and  repeats  them  to  him.  Such  conditions  may 
lead  to  a  kind  of  doubling  of  the  personality :  a  person  hears 
more  than  one  voice  speaking  in  him,  and  is  unable  to  distin- 
guish his  own. 

Hallucinations  of  smell  are  very  common  and  usually 


ELEMENTARY  ANOMALIES  OF  THE  MIND.  31 

of  an  unpleasant  kind;  the  latter  may  be  said  of  those  of 
taste  which  are  much  less  common. 

Hallucinations  (illusions)  of  superficial  (cutaneous) 
sensibility  are  common  and  take  the  forms  of  formication, 
tickling,  electric  irritation,  etc.  Allied  to  these  are  hallu- 
cinations of  the  sense  of  temperature. 

Hallucinations  of  movement  may  depend  upon  anomalies 
in  the  interpretation  of  sensations  coming  from  the  skin, 
joints,  muscles  etc. 

There  are  also  organic  hallucinations,  in  which  anomalies 
of  sensation  are  referred  to  bodily  organs — the  heart,  stom- 
ach, liver,  etc.  However,  the  bodily  organs  are  more  fre- 
quently causes  of  illusions  derived  from  pathologic  processes 
affecting  them. 

Hallucinations,  owing  to  their  power  to  convince,  have  a 
marked  influence  on  conduct,  especially  if  they  be  often  re- 
peated or  constant.  In  some  cases  of  mental  disease  they 
are  only  occasional  symptoms ;  in  others  they  are  constant 
and  form  the  basis  of  all  the  mental  symptoms.  They  may 
affect  one  sense  or  several  senses  simultaneously. 

Perception,  in  contrast  with  the  conditions  of  hyperesthe- 
sia essential  to  hallucination,  may  take  place  with  abnormal 
slowness,  a  condition  dependent  on  hypesthesia  or  anesthesia 
of  the  mechanism  of  sense-perception.  This  condition  may 
affect  one,  several,  or  all  of  the  senses. 

Normally,  perception  is  practically  immediate;  but  with 
hypesthesia  or  anesthesia  of  the  mechanism  of  sense-per- 
ception the  percept  develops  after  an  appreciable  interval, 
sometimes  quite  long.  This  anomaly  is  especially  frequent  in 
forms  of  organic  dementia,  and  in  melancholia.  The  psychic 
result  is  inability  to  reproduce  (remember)  events  or  sense- 
impressions;  for  sense-impressions  must  have  a  certain  de- 


32  OUTLINES  OF   PSYCHIATRY. 

gree  of  intensity  to  make  possible  their  re-awakening  in  con- 
sciousness, and  hypesthesia  of  sense-perception  must  be  due 
to  faintness  as  well  as  slowness  in  the  process  of  evocation  of 
the  percept. 

Disturbances  oe  the  process  oe  thinking  may  be 
classified  in  accordance  with  certain  characteristics : — 

1.  Certain  thoughts  or  series  of  mental  images  (ideas) 
may  take  possession  of  consciousness  and  dominate  the  mind 
absolutely.     They  are  called  imperative  and  insistent  ideas. 

All  have  had  experience  of  some  tune  continuing  persist- 
ently in  thought  or  recurring  insistently  in  spite  of  every 
effort  to  banish  it.  This  illustrates  the  imperative  idea, 
which  may  form  a  very  important  symptom  in  some  forms  of 
insanity,  and  lead  to  acts  of  the  most  insane  kind. 

2.  Abnormal  rapidity  oe  the  process  of  think- 
ing is  due  to  increased  facility  of  association  of  ideas 
(images),  without  power  of  control.  It  is  essentially  due 
to  comparative  equalization  of  intensity  of  all  sense-percep- 
tions as  a  result  of  which  attention  is  directed  here  and  there 
in  accordance  with  the  simplest  law  of  association  of  ideas, 
and  with  a  rapidity  impossible  when  attention  is  controlled 
by  the  predominance  of  intensity  of  certain  perceptions  and 
ideas.  The  rapidity  of  ideational  associations  may  become 
so  great  that  confusion  of  ideas  results — incoherence.  In 
cases  of  this  kind  it  is  often  apparent  that  reproduced  images 
take  control  in  the  association  of  ideas,  and  the  patient  lives 
in  a  dream  of  a  multitude  of  ideas,  simply  and  rapidly  asso- 
ciated, to  the  exclusion  of  sense-perception.  When  a  patient 
lives  in  his  reproduced  ideas  to  the  exclusion  of  sense-per- 
ception, he  is  in  a  state  of  delirium;  when  external  impres- 
sions have  power  to  modify  his  rapid  association  of  ideas, 
he  is  said  to  be  maniacal.     Between  the  mild  degree  of  ac- 


ELEMENTARY  ANOMALIES  OF  THE   MIND.  33 

celeration  of  ideational  associations,  with  the  usual  accom- 
panying emotional  state  known  as  maniacal  exaltation,  and 
the  wild  incoherence  of  delirium  with  predominance  of  re- 
produced images,  lie  many  degrees  of  intensity  of  the  flow 
of  thought.  Conventionally  we  distinguish  maniacal  exal- 
tation, mania,  furious  mania,  and  delirium. 

3.  Abnormal  slowness  of  the  process  of  think- 
ing is  allied  to  abnormal  slowness  of  sense-perception;  the 
former  is  the  necessary  result  of  the  latter,  though  there  is 
no  necessary  connection  between,  them.  Slowness,  or  more 
correctly,  want  of  play  of  association  of  ideas,  exists  with 
the  imperative  idea ;  this  is  the  end  of  association, — the  per- 
sistence of  one  idea.  True  slowness  of  thinking  is  either  the 
result  of  slowness  of  sense-perception  due  to  organic  defect, 
or  of  insistence  of  idea.  In  case  of  organic  defect  the  slow- 
ness of  thought  is  actual;  in  case  of  insistence  of  idea,  it  is 
virtual.  In  the  former  case  the  slowness  of  thought  depends 
upon  want  of  ideas  or  percepts ;  in  the  latter  the  slowness  or 
arrest  of  association  of  ideas  is  due  to  the  control  exercised 
by  one  idea,  which  does  not  permit  percepts  or  ideas  foreign 
to  it  to  exercise  their  influence  on  the  play  of  thought.  Ap- 
parent slowness  of  thought  is  characteristic  of  states  of 
depression  of  feeling;  but  delay  of  the  process  of  thought  in 
emotional  depression  is  actual  only  in  states  of  depressive 
stupor,  in  which  stupor  reproduces  a  temporary  condition 
like  that  of  actual  physical  defect  of  the  nervous  mechanism 
of  perception  and  reproduction. 

The  slowness  of  thought  attributed  to  melancholia  is 
not  necessarily  actual,  but  rather  apparent  as  a  result  of 
monotonous  pre-occupation  with  ideas  of  a  certain  kind 
having  a  certain  emotional  coloring.  This  is  proved  by  the 
well-known  fact  that  after  recovery,  those  that  have  suffered 


34  OUTLINES   OF   PSYCHIATRY. 

with  melancholia  of  a  degree  less  than  that  of  stupor  have  a 
perfect  memory  of  all  the  events  during  their  depression; 
furthermore,  by  the  fact  that  melancholiacs  accept  imme- 
diately all  sense-perceptions  in  accord  with  the  predominating 
ideas,  or  immediately  distort  others  to  bring  them  into  ac- 
cord with  the  predominating  depressive  ideas.  This  is  not, 
then,  slowness  of  association  of  ideas,  bul~restriction  of  as- 
sociation of  ideas,  which  naturally  becomes  monotony  and 
poverty  of  ideas,  conditions  of  which  melancholiacs  often 
complain,  and  it  is  closely  allied  to  the  imperative  idea. 

The  monotony  of  thought  of  melancholia  sometimes 
makes  it  difficult  to  establish  a  differential  diagnosis  between 
it  and  dementia. 

""Memory  is  the  faculty  of  reproduction  in  consciousness 
of  percepts,  ideas,  and  associations  of  ideas  (concepts). 
This  faculty  presents  three  kinds  of  disorder :  intensification, 
defect,  and  error  of  reproduction,  called  respectively,  hy- 
permnesia,  amnesia  and  paramnesia. 

1.  Hypermnesia  as  an  abnormal  phenomenon  may  be 
understood  by  the  variations  that  the  faculty  of  memory 
normally  presents.  We  can  all  recall  times  when  the  mem- 
ory acted  sluggishly  and  others  when  past  impressions  came 
into  consciousness  with  remarkable  clearness  and  precision 
of  detail.  This  intensification  of  memory-pictures  that  oc- 
curs normally  under  certain  circumstances,  is  the  beginning 
of  the  milder  degree  of  pathologic  intensification  of  memory, 
which  occurs  in  certain  insane  states  especially  characterized 
by  increase  of  facility  of  association  of  ideas  (mania), and  in 
which,  probably  as  an  underlyng  cause  of  the  increase  of 
association  of  ideas,  there  is  a  crowding  into  consciousness 
of  memory-pictures  with  equalization  of  value  of  detail, 
so  that  there  is  a  re-awakening  in  memory  of  details  which 


ELEMENTARY  ANOMALIES  OF  THE  MIND.  35 

normally  would  make  no  impression  on  consciousness  and 
have  no  effect  on  the  association  of  ideas.  This  is  per- 
haps best  illustrated  by  the  comparison  of  the  camera 
and  the  resulting  photograph  with  the  mental  faculty  of 
perception  and  reproduction  of  the  resulting  mental  image. 
The  camera  registers  on  the  sensitive  plate  all  details;  so 
the  senses  register  all  details  of  impressions  in  the  cortical 
centers.  The  registration  of  details  by  the  camera  is  me- 
chanical; so  is  the  registration  of  the  details  made  on  the 
senses  by  external  impressions.  In  the  photograph  objects 
most  perfectly  in  focus  are  rendered  with  greatest  fidelity, 
and  give  the  character  to  the  photograph;  so  sense-impres- 
sions induce  percepts  having  a  character  dependent  upon  the 
predominating  intensity  or  force  of  certain  elements  that 
fall  within  the  "focus"  of  consciousness.  It  is  these  salient 
features  (principal  elements  of  perceptual  activity)  that  are 
normally  reproduced  in  voluntary  memory;  the  lesser  de- 
tails, being  without  the  "focus"  of  consciousness,  are 
registered  for  reproduction  in  organic  memory.  Atten- 
tion acts  like  the  diaphragm  of  a  microscope,  to  cut  off 
certain  portions  of  the  perceptual  field  from  entrance  into 
consciousness.  However,  all  details  in  the  perceptual  field 
are  registered  (photographed).  When  the  limiting  action 
of  attention  is  arrested,  all  memory-pictures  come  into  con- 
sciousness but  without  perspective;  so  that  extraordinary 
avenues  of  ideational  association  are  opened  which  thus 
make  possible  intensification  of  memory. 

The  voluntary  exercise  of  memory  meets  with  many 
normal  obstacles  which  training  of  attention  overcomes  to 
some  degree;  profound  and  permanent  defects  and  loss  of 
this  power  are  due  to  organic  cerebral  disease.  

Pathologic  intensification  oe  memory  (intensifica- 


36  OUTLINES  OF   PSYCHIATRY. 

tion  and  increased  facility  of  the  reproduction  of  images)  is 
comparable  to  dreaming.  Dreams  are  often,  if  not  always, 
characterized  by  the  reappearance  in  consciousness  of  details 
which  are  wanting  to  voluntary  exercise  of  the  faculty  of 
memory,  and  the  play  of  association  of  ideas  in  dreaming 
may  be  very  aptly  compared  to  the  same  process  as  observed 
in  mania:  the  intensification  of  memory-pictures  is  of  the 
same  kind — involuntary  and  without  other  guidance  than 
that  resulting  from  organic  conditions. 

2.  Amnesia  means  absence  of  memory,  but  as  com- 
monly employed  it  is  applied  to  various  degrees  and  kinds 
of  defect  of  this  faculty.  Amnesia  may  affect  all  or  only 
a  part  of  previously  acquired  mental  images. 

General  amnesia,  more  or  less  pronounced,  is  a  promi- 
nent symptom  of  general  mental  weakness.  It  also  results 
from  profound  disturbance  of  consciousness  from  any  cause 
for  the  period  of  the  disturbance. 

Temporary  loss  oe  consciousness  oe  sele  is  a  state 
of  loss  of  memory  of  past  events  of  the  period  of  its  continu- 
ance. 

Doubling  oe  the  personality,  through  the  creation  of 
two  series  of  memory-pictures  for  two  states  of  conscious- 
ness, which  may  alternate,  is  a  phenomenon  dependent  in  its 
beginning  on  loss  of  self-consciousness,  and  creation  of  an- 
other series  of  memory-pictures  out  of  which  grows  the 
second  personality. 

Partial  amnesias  are  very  common.  There  may  be 
loss  of  memory  of  events  of  early  experience,  with  perfect 
memory  of  recent  events,  or  vice-versa.  In  ordinary  cases 
of  amnesia  the  defect  is  for  recent  events,  and  is  the  rule 
when  manifest  in  old  age. 

Retroactive    amnesia   is  a  term   applied  to   loss  of 


ELEMENTARY  ANOMALIES  OF  THE  MIND.  37 

memory  for  events  anterior  to  the  period  of  the  mental  dis- 
turbance which  causes  it,  in  the  sense  that  the  defect  of 
memory  is  distinctly  limited  to  a  certain  period.  For  example, 
a  man  receives  a  blow  on  the  head  and  becomes  unconscious ; 
on  regaining-  consciousness  he  remembers  nothing  of  the 
period  of  unconsciousness,  nothing  of  its  cause,  and  nothing 
for  a  certain  period  anterior  to  the  blow.  This  period  may 
extend  back  hours,  days,  and  rarely  years. 


LESSON  VI. 
Delusions. 

Memory  and  association  of  ideas  are  at  the  foundation 
of  intellectual  activity,  which  in  its  higher  forms  is  repre- 
sented by  concepts  and  judgments  resulting  from  what  we 
know  as  logical  reasoning.  Normally  our  judgments  are 
often  erroneous;  we  are  deceived  by  our  senses,  or  deceive 
ourselves  by  an  erroneous  process  of  reasoning.  Any  idea, 
opinion,  or  belief  that  is  not  in  harmony  with  facts,  is  a  de- 
lusion. Belief  in  the  actuality  of  an  illusion  or  hallucination 
is  a  delusion. 

There  are  sane  and  insane  delusions.  Sane  delusions  are 
illustrated  every  day  in  erroneous  beliefs  based  on  education 
and  sentiment.  The  history  of  the  progress  of  mankind  is 
a  record  of  the  dissipation  of  delusions — of  false  opinions 
about  the  material  world.  Sane  delusions  may  be  persistent, 
and  usually  they  are  very  difficult  to  overcome  if  they  have 
their  root  in  faulty  education.  Formerly  all  Christendom 
believed  in  witchcraft;  it  took  centuries  to  eradicate  this  de- 
lusion in  the  majority ;  it  still  persists  in  some  classes  of  the 
ignorant.  The  persistence  of  a  false  idea  even  in  the  face  of 
proof  of  its  falsity  does  not  stamp  it  as  abnormal,  and  a  false 
idea,  as  such,  is  no  evidence  of  an  insane  state  of  mind. 

An  insane  delusion  is  one  that  can  be  shown  to  have  a 

38 


PATHOLOGIC    DELUSIONS.  39 

pathologic  origin;  or  which  is  manifested  in  accordance  with 
the  known  laws  that  control  insane  symptoms. 

An  important  characteristic  of  the  insane  delusion  is  im- 
mediate relation  to  the  Ego,  the  person. 

An  insane  delusion  is  not  necessarily  an  impossible  idea, 
nor  an  unusual  idea;  the  ostensible  insane  character  of  it 
may  arise  simply  from  its  effect  on  the  conduct,  or  its  rela- 
tion to  the  previous  education  of  the  individual  entertain- 
ing it. 

To  make  these  points  clear  illustrations  are  necessary. 
A  person  believes,  for  example,  that  the  sun  stood  still 
for  Joshua.  This  is  a  matter  of  belief  based  upon  education 
and  religious  faith,  and  has  no  personal  concrete  meaning. 
The  insane  individual  asserts  that  like  Joshua's  sun  in  Ajalon 
the  sun  was  arrested  in  its  course  for  him  and  cites  subjective 
proofs  that  convince  himself  but  no  one  else.  In  the  first 
instance  whether  the  person  entertains  a  delusion  or  not,  is 
a  question  of  faith ;  in  the  second  case,  the  individual  is 
certainly  deluded  in  the  eyes  of  all ;  his  personal  experience 
is  immediately  regarded  as  abnormal  because  the  experience 
and  reasoning  of  all  are  in  contradiction  with  his  assertion. 
He  has  transformed  his  belief  in  a  miracle  into  concrete 
subjective  experience — given  it  a  personal  application. 
The  pathology  of  such  a  case  lies  in  the  loss  of  relation  be- 
tween the  real  and  the  abstract.  The  delusion  is  based  on  the 
normal  belief  in  the  possibility  of  repetition  of  a  miracle, 
and  the  subjective  abnormal  conditions  which  allow  imagi- 
nation to  take  control  of  consciousness  to  the  exclusion  of  the 
immediate  evidence  of  the  senses  derived  from  the  objective 
world.  The  belief  of  a  single  individual  of  having  experi- 
enced an  arrest  of  movement  of  the  heavenly  bodies  must 
rest  upon  subjective  experience,  not  upon  objective  reality, 


40  OUTLINES   OF   PSYCHIATRY. 

and  therefore  must  be  due  to  abnormal  conditions  in  the  in- 
dividual and  necessarily  have  a  direct  relation  to  the  Ego. 

All  educated  persons  know  that  the  earth  turns  on  its 
axis,  without,  however,  having  any  proof  of  the  fact ;  astron- 
omers proved  this  fact  by  a  process  of  reasoning,  but  physi- 
cal demonstration  of  it  was  not  made  until  the  fifth  decade  of 
the  nineteenth  century.  The  dictum  of  the  learned  was  finally 
accepted  by  those  educated  by  them,  and  at  the  present  time 
mankind  accepts  through  belief  a  physical  fact,  which  not 
one  in  ten  thousand  could  demonstrate  to  the  satisfaction  of 
one  educated  to  believe  the  contrary.  There  is  no  better 
proof  than  this  that  it  is  not  the  nature  of  an  idea  that  is 
abnormal,  but  the  manner  of  its  origin. 

Copernicus  was  considered  demented  by  Bacon  because 
the  Copernican  theory  seemed  extraordinary  to  that  reputed 
man  of  science;  thus,  what  is  or  seems  extraordinary  is  not 
a  sign  of  insanity.  However,  ideas  that  are  absurd  or  im- 
possible may  have  at  once  the  color  of  abnormality,  as  when 
one  tells  us  he  has  built  a  ladder  to  the  moon.  Persons  that 
actually  entertain  such  absurd  delusions  never  feel  any  need 
to  prove  their  assertions ;  a  fact  which  serves  to  distinguish 
such  insane  delusions  from  similar  fantastic  or  impossible 
ideas  assumed  to  simulate  insanity.  The  logic  of  the  sane 
mind  is  uncontrollable  by  the  will ;  a  sane  mind  may  assume 
to  be  possessed  by  a  delusion,  but  th&Uogk.  of  a  rational 
thought  can  always  be  detected  in  a  close  analysis  of  the  rela- 
tion of  the  assumed  delusion  to  the  process  of  thought  as  re- 
vealed in  action  and  description. 

To  show  that  a  delusion  need  not  be  unusual  or  impossi- 
ble, analyze  the  common  delusion  of  alcoholic  insanity  in  the 
husband — he  believes  his  wife  unfaithful;  unfaithfulness  is 
not  impossible  or  extraordinary.     In  such  a  case  it  is  unim- 


DELUSIONS.  41 

portant  whether  the  wife  is  false  or  not ;  the  important  point 
is  to  ascertain  how  the  husband  came  to  develop  the  idea; 
in  other  words  to  ascertain  the  subjective  manner  of  its 
origin. 

Insane  delusions  may  be  divided  into  classes  in  accord- 
ance with  certain  characteristics  they  present. 

Expansive  delusions  are  those  characterized  by  in- 
crease in  the  valuation  of  self,  and  this  is  the  basis  of  so- 
called  grand  delusions,  or  delusions  of  grandeur  (megalo- 
mania). 

Grand  delusions  may  be  primary  or  secondary  and 
concern  any  of  the  relations  or  powers  of  the  individual.  The 
patient  may  believe  himself  an  extraordinary  personage — a 
king,  an  emperor,  a  god ;  he  may  fancy  himself  the  possessor 
of  millions  of  money,  of  horses ;  he  may  be  convinced  that  he 
is  an  example  of  physical  perfection  and  beauty,  or  possessed 
of  unexampled  intellectual  power  and  genius,  or  a  religious 
savior  of  the  world.  The  sexual  mental  element  is  often  im- 
plicated :  men  have  unheard  of  sexual  power ;  women  have 
borne  five  hundred  children  or  have  had  a  miraculous  con- 
ception and  borne  a  god.  The  majority  of  grand  delusions 
are  striking  on  account  of  their  absurdity. 

Depressive  delusions  are  such  as  have  an  accompani- 
ment of  melancholy,  or  sadness,  and  they  have  also  very 
often  as  a  basis  underestimation  of  self,  or  conviction  of  un- 
worthiness  or  powerlessness.  Thus  there  arise  delusions  of 
sin,  of  neglect  of  duty,  of  being  the  cause  of  all  the  misfor- 
tunes of  the  world,  of  all  disease,  etc.  Such  depressive  ideas 
may  take  on  an  inverse  character  of  grandeur  (micromania). 

Depressive  delusions  are  very  frequently  logically  accom- 
panied by  ideas  of  punishment,  and  the  patients  come  often 


42  OUTLINES  OF   PSYCHIATRY. 

to  believe  that  they  are  the  object  of  pursuit  by  officers  or  of 
vengeance  of  higher  powers. 

Depressive  delusions  are  said  to  be  hypochondriacal  when 
their  content  is  a  false  idea  of  the  body  itself, — of  being 
diseased  beyond  remedy,  of  being  a  source  of  contagion,  etc. 

Delusions  of  persecution  form  a  very  important  cate- 
gory of  insane  delusions.  A  person  so  afflicted  believes  him- 
self to  be  the  object  of  persecution  in  some  form. 
The  melancholy  patient,  if  entertaining  a  delusion  of  per- 
secution, acknowledges  that  he  deserves  his  suffering,  for  he 
has  done  something  to  cause  it;  the  melancholic  ideas  of 
persecution  grow  out  of  the  ideas  of  sin,  etc.,  and  have  no 
other  meaning  than  the  emotional  state  from  which  they 
spring. 

Primary  delusions  oe  persecution  have  special  sig- 
nificance owing  to  their  profound  influence  in  distorting  the 
personality.  They  owe  their  origin  to  an  abnormal  intensi- 
fication of  the  sense  of  the  importance  of  the  Ego  as  related 
to  others  and  the  world,  in  a  person  having  logical  powers 
of  thought  and  acuteness  of  observation.  Primary  delusions 
of  grandeur  also  rest  upon  intensification  of  the  sense  of  the 
importance  of  the  Ego,  but  for  this  to  result  in  grand  delu- 
sions there  must  be  defect  in  the  logical  powers  of  thought 
and  defect  of  observation.  Primary  delusions  of  grandeur 
indicate  an  intellect  originally  of  a  low  order;  primary  de- 
lusions of  persecution  indicate  a  higher  order  of  intellect. 

The  development  of  primary  delusions  of  persecution 
may  be  traced  as  follows  :  increase  of  self-consciousness  lead- 
ing to  pre-occupation  with  the  Ego,  with  consequent  over- 
estimation  of  the  value  and  importance  of  self  (the  individ- 
ual feels  "big"  and  gradually  assumes  an  air  of  superiority 
to  others)  ;  this  mental  attitude  finds  no  acknowledgment  in 


DELUSIONS.  43 

others,  but  rather  meets  with  obstacles  in  ridicule  or  efforts 
to  repress  or  overcome  it.  These  obstacles  become  a  source 
of  reflection  to  the  patient;  and  convinced  of  his  own  value 
and  superiority  he  can  only  conclude  that  the  refusal  of 
others  to  accept  his  own  estimate  of  himself  is  a  kind  of 
persecution.  The  idea  of  persecution  once  awakened,  the 
persecution  becomes,  by  a  process  of  reasoning',  a  proof  of 
the  justice  of  heightened  self-estimation,  and  is  explained 
as  the  result  of  envy  and  jealousy  on  the  part  of  others,  who 
thus  indirectly  acknowledge  the  individual's  superiority. 
Thus  a  suspicious,  expectant  state  of  mind  has  arisen,  and 
the  patient  gradually  comes  to  see  and  expect  a  hostile  atti- 
tude in  everything;  so  that  his  personal  relations  to  the 
world  become  distorted. 

If  hallucinations  be  added,  as  they  usually  are,  they  serve 
to  render  the  persecution  precise,  and  the  delusion  of  persecu- 
tion is  fully  developed  and  becomes  a  controlling  idea 
around  which  all  other  ideas  are  logically  grouped — a  system 
of  delusions  is  developed.  The  original  self-overestimation 
may  ultimately  lead  to  systematized  delusions  of  grandeur 
through  those  of  persecution ;  this  change  from  primary  de- 
lusions of  persecution  to  ideas  of  grandeur,  is  called  the 
transformation,  and  indicates  a  decided  change  of  relations 
of  ideas  and  feelings.  In  the  first  period  the  sense  of  perse- 
cution outweighs  the  feeling  of  self-aggrandizement  and 
controls  thought  and  action ;  in  the  second  period  the  original 
feeling  of  self-importance,  now  fully  developed,  takes  con- 
trol, and  the  delusions  of  persecution  become  inferior  to  the 
delusions  of  grandeur.  It  is  an  indication  of  lowering  of 
mental  power;  for  the  patient  becomes  entirely  controlled 
by  subjective  feelings  and  ideas  and  pays  no  heed  to  the 
logic  of  external  events. 


44  OUTLINES  OF   PSYCHIATRY. 

This  description  serves  to  explain  the  fact  that  primary 
delusions  of  grandeur  are  an  indication  of  feeble  mental 
powers,  due  to  pre-occupation  with  internal  feelings  and 
ideas,  made  possible  by  the  lack  of  power  to  appreciate  the 
logic  of  the  external  world. 

Delusions  of  jealousy  form  an  important  variety  of 
delusions  implicating  the  personality  in  its  sense  of  self- 
esteem. 

A  noteworthy  variety  of  persecutory  insanity  is  that  of 
quarrelsome  persons  who  are  constantly  at  legal  war  with 
their  neighbors  and  friends  and  finally  with  the  law  itself, 
as  a  form  of  persecution  (querulous  insanity). 

But  not  all  querulous  persons  are  insane,  though  pre- 
disposed to  become  so;  just  as  all  over-conceited  persons  are 
not  insane,  though  possible  candidates  for  the  insanity  of  per- 
secution or  grandeur. 

The  content  or  nature  of  the  ideas  that  make  a  delusion 
are  as  varied  as  individuals  and  circumstances  of  life  and 
education. 

Primary  delusions  are  such  as  form  the  starting  point 
of  the  insane  state. 

Secondary  delusions  are  those  that  arise  from  some 
previous  mental  anomaly :  preceding  delusions ;  emotional 
states  (depression,  exaltation)  ;  hallucinations. 

Many  delusions  may  be  combined  in  a  great  variety  of 

forms.     When  several  come  to  be  associated  in  a  logical 

system  of  relation,  they  are  said  to  be  systematized,  and  then 

the  system  of  delusions  acts  as  a  whole  to  control  the  mind 

'of  the  patient. 

Delusions  may  be  fixed  or  changeable;  they  may  be 
constant  or  interrupted. 

The  theory  of  "Monomania"  was  the  result  of  the  as- 


DELUSIONS.  45 

sumption  that  certain  persons  were  insane  (deluded)  on  one 
subject  and  sane  on  all  others.  Practically,  however,  it  is 
found  that  there  is  no  such  thing  as  a  single  fixed  insane 
delusion  in  an  insane  person;  careful  examination  always 
reveals  others,  or  other  mental  anomalies ;  the  presumed 
monomania  only  designates  a  predominating  false  idea. 

A  fundamental  characteristic  of  the  insane  delusion  is 
that  it  cannot  be  corrected  or  overcome  by  any  proof  of 
its  falsity;  but  in  this  it  does  not  differ  from  certain  sane 
delusions.  However,  the  causes  of  this  impossibility  of  cor- 
rection of  sane  and  insane  delusions  are  quite  different.  The 
insane  delusion  cannot  be  corrected  because  it  has  its  origin 
in  subjective  ideas  and  associations  of  ideas  that  depend 
upon  abnormal  conditions  of  the  brain.  The  sane  delusion 
cannot  be  immediately  corrected  because  it  is  an  opinion  or 
belief  not  susceptible  of  immediate  material  refutation ;  itself 
the  product  of  experience  and  teaching,  it  may  require  com- 
paratively long  experience  and  teaching  to  eradicate  it. 

The  relations  of  insane  delusions  to  the  feelings  and 
other  elementary  psychic  anomalies  will  find  ample  subse- 
quent illustration ;  and  their  effect  on  conduct  will  also  be 
made  clear  in  the  discussion  of  the  various  types  of  insanity. 

The  possibility  of  concealment  of  delusions  is  an  import- 
ant fact  that  will  receive  due  consideration  in  the  following 
lessons. 


LESSON  VII. 
Anomalies  oe  the  Feelings. 

The  feelings  may  be  divided  into  those  of  organic  or 
bodily  nature  and  those  of  a  moral  kind. 

The  bodily  feelings  are  hunger,  thirst,  sexual  feeling,  and 
the  feeling  of  fatigue  and  its  opposite;  fatigue  leads  to  the 
feeling  or  desire  for  sleep. 

These  organic  feelings  may  be  disturbed  in  three  ways  : — 
increased,  decreased,  perverted.  These  disorders  often  form 
a  part  of  insanity,  though  they  may  be  independent  of  the 
general  mental  state  and  afford  physical  rather  than  mental 
indications. 

Examples  of  increase  are  afforded  by  the  inordinate 
appetite  of  idiots  and  imbeciles  and  in  certain  forms  of  in- 
sanity like  paretic  dementia  and  certain  stages  of  mania. 

Increase  of  thirst  for  a  physical  reason  occurs  in  cer- 
tain forms  of  diabetes ;  for  a  mental  reason  it  is  observed 
in  cases  of  dipsomania,  in  which  the  thirst  is  for  alcoholic 
drinks. 

Increase  of  sexual  feeling  or  desire  is  often  a  symptom 
of  certain  mental  diseases  characterized  by  general  nervous 
excitation — mania,  paretic  dementia, — and  it  leads  to  sexual 
excesses  in  coitus  or  masturbation. 

Similarly,  in  some  conditions    (maniacal),  there  is  an 

46 


ANOMALIES  OF  THE  FEELINGS.  47 

increase  in   the  general    feeling  of  bodily   well-being  and 
strength  that  is  the  opposite  of  fatigue. 

Decrease  or  absence  of  desire  for  food  presents  itself  in 
all  degrees  of  anorexia  in  certain  forms  of  insanity,  up  to 
absolute  refusal  of  food.  Lack  of  thirst  is  exemplified  in 
hydrophobia  and  in  the  intervals  of  dipsomania  and  in  mel- 
ancholia. 

Diminution  of  sexual  desire  occurs  in  .depression  of  all 
the  mental  functions,  and  especially  in  certain  organic  men- 
tal diseases — paretic  dementia,  chronic  alcoholic  insanity. 

Fatigue  is  a  normal  result  of  continued  muscular  activ- 
ity, but  it  may  be  abnormal  in  the  sense  that  it  may  appear 
after  slight  exertion.  Its  failure  to  occur,  as  already  noted, 
is  observed  in  states  of  mental  excitement;  its  abnormal 
increase  is  characteristic  of  states  of  mental  depression. 

Perversion  of  the  organic  appetites  is  very  common,  espe- 
cially of  those  for  food  and  for  sexual  gratification.  Per- 
version is  understood  to  mean  desire  for  that  naturally  un- 
desirable, or  aversion  to  that  naturally  desirable. 

Appetite  for  chalk,  earth,  and  other  similar  substances,  is 
well  known.  Certain  insane  patients  delight  in  drinking 
urine  or  eating  excrement;  anthropophagy  is  rarer,  and 
usually  an  element  in  sexual  perversion. 

Sexual  perversion  is  very  important  as  a  mental  anom- 
aly, because  it  always  raises  the  question  of  insanity,  and  is 
a  frequent  symptom  of  insanity.  It  presents  itself  in  various 
forms,  either  alone  as  a  striking  symptom  or  as  one  of  sev- 
eral symptoms  indicating  an  insane  condition. 

Contrary  sexual  feeling  is  a  desire  for  sexual  com- 
merce with  the  same  sex. 

Sadism  is  sexual  gratification  in  the  infliction  of  pain. 


48  OUTLINES  OF   PSYCHIATRY. 

Masochism  is  sexual  pleasure  in  the  experience  of  pain 
or  injury, — physical  or  imaginary. 

Erotic  FETichism  is  sexual  satisfaction  in  relation  to 
some  object  more  or  less  remotely  connected  with  sexuality, 
which  renders  normal  sexual  relations  unnecessary,  repug- 
nant, or  impossible. 

Necrophilia  is  a  desire  for  sexual  congress  with  the 
dead :  a  form  of  ideal  Sadism  or  an  independent  phe- 
nomenon. 

Exhibitionism  is  sexual  gratification  in  exposure  of  the 
genitals,  either  as  an  object  in  itself,  or  as  a  means  of  obtain- 
ing ultimate  sexual  satisfaction  in  another  form. 

Sexual  abuse  of  children  is  another  form  of  sexual 
perversion. 

Incest,  either  hetrosexual  or  homosexual,  is  a  form  of 
psycho-sexual  perversion. 

All  these  perversions  are  more  or  less  closely  allied  to 
insanity  in  its  various  forms. 

Finally  masturbation  may  be  regarded  as  a  sexual  per- 
version; for  it  often  renders  natural  desire  impossible,  and 
becomes  the  starting  point  of  other  forms  of  sexual  per- 
version. 

Normally  we  experience  a  feeling  of  well-being,  of 
health ;  in  the  beginning  of  disease  we  have  a  feeling  of 
malaise,  of  sickness.  Such  feelings  are  the  result  of  many 
factors.  In  insanity  this  general  feeling  may  present  vari- 
ous disturbances.  There  may  be  a  feeling  of  well-being 
when  the  patient  is  very  far  advanced  in  disease;  or  the 
feeling  of  sickness  may  be  experienced  and  fully  appre- 
ciated. 

The  moral  feelings  present  likewise  abnormal  in- 
crease, decrease,  or  perversion. 


ANOMALIES  OF  THE  FEELINGS.  49 

There  is  no  fixed  standard  of  moral  sensibility,  and  we 
can  regard  extremes  only  as  abnormal;  but  without  other 
symptoms  of  insanity,  even  extreme  expressions  of  moral 
sensibility  do  not  suffice  to  establish  the  existence  of  insanity. 

In  insane  conditions  we  meet  increase  of  religious  feel- 
ing, unreasonable  piety ;  extreme  altruism,  unreasoned  char- 
ity; excessive  moral  sensitiveness  to  evil  in  all  its  forms 
which  makes  it  impossible  to  reason  with  it.  Such  states  of 
moral  feeling,  when  exaggerated,  though  possibly  without 
insanity,  are  exemplified  in  the  founding  of  hospitals  and 
cemeteries  for  cats  and  dogs  and  canaries;  in  the  ^///-move- 
ments of  idealistic  reformers  in  the  effort  to  ameliorate  the 
condition  of  beasts  of  burden.  Such  efforts  are  based  upon 
hypersensitiveness  of  a  certain  kind  and  rarely  directed 
rationally  to  discover  and  remedy  causes.  It  is  also  remark- 
able that  persons  who  wage  campaigns  for  beasts  are  very 
insensible  to  the  sufferings  of  humanity.  The  use  of  chlor- 
oform in  confinement  was  long  tabooed  because  woman  was 
destined  to  bring  forth  in  pain.  Anti-alcoholic  enthusiasm 
finds  extreme  manners  of  expression  that  have  no  relation  to 
reason. 

Decrease  or  want  of  moral  feeling  (moral  indiffer- 
ence) is  a  very  common  symptom  of  insanity.  It  is  char- 
acteristic of  paretic  dementia,  alcoholic  insanity,  epilepsy, 
and  hysteria. 

A  special  form  of  this  defect  is  called  "Moral  Insanity." 
Moral  imbecility  is  a  better  term  for  the  condition ;  for  so- 
called  moral  insanity  is  not  an  acquired  but  a  congenital 
condition.  Moral  anomalies  are  frequent  symptoms  of  in- 
sanity, but  moral  insanity  is  a  term  applied  to  cases  in  which 
there  was  never  any  moral  development,  but  in  which  sharp- 
ness of  intellect  was  not  wanting.    There  are  children  that 


50  OUTLINES   OF   PSYCHIATRY. 

never  experience  filial  feeling,  and  who  yet  go  through  life 
without  other  remark  than  that  they  are  devoid  of  natural 
feeling;  so  there  are  individuals  in  whom  the  common  feel- 
ings of  pity,  compassion,  tenderness,  and  a  sense  of  right 
and  wrong,  are  never  developed;  in  whom  all  actions  are 
based  upon  the  experience  of  egotistic  utility.  Such  individ- 
uals are  moral  imbeciles,  and  in  certain  cases  the  defect  is 
so  marked  that  the  individual  is  constantly  in  conflict  with 
society  and  regarded  as  insane  or  a  criminal.  Moral  imbe- 
ciles may  become  criminal,  but  not  all  criminals  are  moral 
imbeciles. 

Change  of  moral  feeling  as  expressed  in  the  attitude  to- 
ward the  family,  the  influence  of  moral  ideas  in  general, 
with  reference  to  good  and  evil,  to  self-respect,  honor  and 
duty,  is  one  of  the  earliest  and  most  delicate  tests  of  the  de- 
velopment of  an  abnormal  mental  condition.  Gross  and 
open  infraction  of  moral  lazv  in  one  formerly  solicitous  to 
fulfill  moral  obligations,  is  practically  a  sure  indication  of 
mental  disease. 

Perversion  of  moral  feeling  is  exemplified  in  natural  or 
acquired  perversity  which  finds  pleasure  in  the  suffering  of 
others,  is  devoid  of  a  sense  of  shame,  and  takes  delight  in 
lying.  There  are  pathologic  liars  of  various  degrees ;  cruel, 
shameless  liars  are  usually  so  from  original  defect  or  im- 
perfect development. 

The  state  oe  feeling,  or  the  emotional  mental 
condition,  is  made  up  of  all  the  feelings  or  emotions  pres- 
ent in  consciousness  at  a  given  moment.  This  general  emo- 
tional state  is  the  result  of  very  complex  interrelation  of 
elementary  feelings,  and  is  of  great  importance,  when  dis- 
turbed, as  an  aspect  of  insanity. 

From  the  standpoint  of  psychopathology  the  most  im- 


ANOMALIES  OF  THE  FEELINGS.  51 

portant  emotional  states  are  depression  (melancholy),  ela- 
tion (mania),  fear  (phobias),  and  anger  (furious  mania). 

Absence  of  any  definite  emotional  coloring  occurs,  and 
if  persistent  leads  to  a  state  of  dullness  of  feeling, — emo- 
tional indifference. 

Normally  the  play  of  the  emotions  presents  infinite  varia- 
tions in  obedience  to  internal  and  external  causes.  In  cer- 
tain forms  of  insanity  often  there  is  a  marked  increase  in  the 
emotional  activity ;  in  others  there  is  persistent  monotony  of 
the  emotional  state. 

When  the  emotions  take  control  and  become  the  cause 
of  wild  acts,  we  speak  of  the  condition  as  an  affect.  Acts 
of  blind  anger,  of  fury,  of  despair,  are  outward  indications 
of  affects  resulting  from  painful  emotional  states;  wild  ex- 
pressions of  joy  spring  from  pleasant  emotional  states.  In 
general  an  affect  causes  clouding  of  consciousness,  so  that 
its  subsidence  leaves  but  an  imperfect  memory  of  the  period 
of  its  existence.  On  the  other  hand,  the  affect  of  fear  may 
lead  to  absolute  motor  inhibition,  so  that  the  individual  is 
paralyzed. 

Emotional  depression  (melancholia,  sadness)  is  a 
symptom  of  many  forms  of  insanity ;  when  primary  it  gives 
its  name  to  a  certain  form  of  disease — melancholia.  It  may 
develop  the  affect  of  despair  (raptus  melancholicus),  or 
paralyze  all  activity  and  induce  mental  torpor  (stupor). 

Emotional  elation  (joy)  is  likewise  a  symptom  of 
various  forms  of  insanity,  but  in  its  primary  uncomplicated 
form  is  called  mania.  The  affects  that  develop  on  this  basis 
are  those  of  wild  joy  and  those  of  furious  anger  and  blind 
psychomotor  activity.  The  melancholic  state  is  monotonous 
and  not  prone  to  find  expression  in  disordered  activity;  the 
joyful  maniacal  state,  on  the  contrary,  is  characterized  by 


52  OUTLINES   OF   PSYCHIATRY. 

variability  of  ideational  accompaniment,  and  very  apt  to 
increase  to  the  affects  of  anger  and  fury.  Tears  and  mo- 
mentary sadness  are  also  seen  in  the  picture  of  mania. 

Phobias  are  fears  which  have  a  pathologic  foundation, 
and  they  may  be  precursors  or  accompaniments  of  insanity. 
A  phobia  is  not  necessarily  a  proof  of  insanity.  Normal 
persons  have  certain  fears  for  various  reasons,  and  phobias 
likewise  arise  from  various  sources.  One  person  has  been 
in  a  runaway,  and  thereafter  is  afraid  and  refuses  to  trust 
himself  in  a  vehicle  drawn  by  a  horse;  another  has  been  in 
a  railway  accident  and  fears  to  travel  on  a  railway ;  another 
has  read  of  microbes,  and  develops  a  fear  of  everything 
dirty;  another  has  a  fear  of  dizzy  heights  from  experience. 
It  is  not  always  possible  to  discover  the  origin  of  a  persistent 
morbid  fear,  for  often  it  has  its  beginning  in  internal  con- 
ditions that  escape  examination.  Undoubtedly  many  cases 
of  phobia  have  their  origin  in  vertigo,  normal  or  abnormal. 
The  sense  of  equilibrium  is  a  matter  of  education ;  it  is  not 
natural  to  have  a  perfect  sense  of  equilibrium  on  heights 
with  absence  of  surrounding  near  objects,  but  it  can  be  so 
cultivated  that  there  is  no  fear  on  high  places.  Doubtless 
aural  vertigo  is  capable  of  causing  fear  of  open  spaces 
{agoraphobia).  Claustrophobia  (fear  of  closed  rooms) 
may  arise  from  cardiac  or  respiratory  disorders,  which  initi- 
ate a  sense  of  oppression  or  of  inability  to  breathe  freely. 
Misophobia  (fear  of  dust  or  dirt)  is  generally  of  purely  in- 
tellectual origin. 

The  importance  of  phobias  will  be  understood  in  the 
later  consideration  of  them  in  their  relation  to  insanity. 

The;  emotion  of  fear  has  a  marked  effect  on  the  circu- 
lation and  respiration ;  on  the  other  hand  disturbances  of  the 
circulation  and  respiration  have  power  to  excite  a  state  of 


ANOMALIES  OF  THE  FEELINGS.  53 

fear  which  to  the  individual  seems  primary  and  without 
cause:  he  is  in  a  state  of  painful  anxiety  and  apprehension 
which  dominates  consciousness  and  holds  him  spellbound. 
Precordial  anxiety  is  a  variety  of  fear  often  met  in  certain 
forms  of  insanity ;  probably  it  is  due  to  or  has  its  origin  in 
sensations  reaching  consciousness  through  the  vagus.  The 
affect  of  fear,  of  course,  may  have  various  bodily  or  mental 
causes  (hallucination).  Its  immediate  effect  is  to  paralyze 
psychomotor  activity  (rigidity  with  tremor)  ;  but  not  in- 
frequently this  is  followed  by  wild  violence  of  activity ;  as  if 
the  motor  centers,  held  too  long  in  check,  had  accumulated 
force  sufficient  to  break  the  bond  of  restraint  imposed  by 
fear. 

General  disturbances  of  consciousness.  Lucid- 
ity is  a  term  used  to  designate  a  state  of  clearness  of  ideas, 
feelings,  etc.,  with  orientation  in  time  and  space.  Insanity 
often  presents  departures  from  this  lucid  or  clear  state  of 
consciousness.  Often  a  patient  appears  lucid  when  his 
lucidity  is  only  partial  or  assumed.  From  this  it  follows  that 
apparent  lucidity  does  not  exclude  insanity. 

In  contrast  with  lucidity  are  confusion  and  incoherence.' 
They  are  revealed  by  incoherent  speech  and  action  which 
indicate  the  Tack  of  order  in  the  association  of  ideas. 
Incoherence  may  be  due  to  temporary  disturbance  of  associa- 
tion of  ideas  (hallucination,  emotions),  or  to  organic  cere- 
bral defect  (paretic  dementia). 

Cloudy  states  of  consciousness  may  be  compared  to 
what  we  experience  between  sleeping  and  waking,  when 
for  a  few  moments  are  mingled  dream-pictures  and  actual 
sense-impressions,  one  or  the  other  of  which  may  take  con- 
trol and  lead  to  acts  more  or  less  unconscious.     They  form 


54  OUTLINES   OF   PSYCHIATRY. 

important  symptoms  of  insanity,  in  which  they  may  be  of 
indefinite  duration. 

Stupor  indicates  a  more  profound  disturbance  of  con- 
sciousness, and  it  presents  itself  in  various  degrees  and  quali- 
ties. We  speak  of  melancholic  and  maniacal  stupor,  of  cata- 
tonic and  hypnotic  stupor,  when  it  is  a  symptom  in  the  course 
of  such  primary  forms  of  mental  disturbance. 


LESSON    VIII. 
Disordered  Acts. — The  Will. 

Owing  to  the  disturbance  of  consciousness  in  insanity 
there  is  increased  possibility  of  reflex  or  subconscious  acts; 
of  acts  which  are  not  the  result  of  mental  reflection  but  of 
direct  transformation  of  sense-impressions  or  ideas  into 
movement.  Such  psychic  reflex  acts  may  be  called  instinc- 
tive if  they  have  their  origin  in  some  sensual  inclination 
(sexuality,  hunger)  ;  or  emotional  when  they  have  as  a 
cause  some  powerful  affect. 

When  the  element  of  mental  reflection  is  interposed  be- 
tween a  stimulus  and  an  act,  the  latter  is  called  volitional, — 
the  ''will"  has  been  interposed.  So-called  voluntary  acts 
(the  outward  expression  of  the  will)  present  two  kinds  of 
disorder, — increase  and  decrease. 

Increase  of  activity  is  observed  in  mania  and  allied 
states  of  excitement ;  decrease,  in  states  of  stupor  and  mental 
inhibition  from  melancholia  and  hallucinations,  and  in  de- 
mentia from  organic  cerebral  causes. 

The  moral  aspect  of  voluntary  acts  in  insanity  forms 
a  most  important  element  of  the  disease.  Conduct  may  in 
many  cases  be  of  the  greatest  value  for  answering  the  ques- 
tion of  the  existence  of  mental  alienation. 

The  presence  of  one  or  more  of  the  elementary  disorders 
of  the  mind  may  suspend  at  any  moment  what  we  regard  as 

55 


56  OUTLINES  OF   PSYCHIATRY. 

the  "will,"  and  the  individual  then  acts  in  harmony  with 
consciousness,  not  in  harmony  with  what  his  education 
would  seem  to  dictate.  Our  moral  ideas  are  the  result  of 
teaching;  our  moral  actions  (morality)  are  the  result  of 
the  predominance  of  these  ideas  over  those  of  a  lower  order. 
Infractions  of  the  laws  of  morality  to  be  symptoms  of  dis- 
ease must  be  shown  to  be  due  to  lack  of  development  of 
moral  ideas,  or  to  loss,  suspension,  or  misinterpretation  of 
them,  as  a  result  of  disease. 

Thus  it  is  clear  that  the  fundamental  elements  of  insanity 
are  disorders  of  the  emotions  and  the  intellect,  and  that  so- 
called  disorders  of  the  "will"  are  merely  expressions  of  one 
or  both  of  the  former. 

Attitude,  facial  expression,  hand-writing,  and 
SPEECH  are  avenues  through  which  morbid  mental  condi- 
tions are  habitually  displayed,  and  their  peculiarities  deserve 
special  mention. 

The  attitude  and  facial  expression  of  melancholia  are 
striking,  with  the  body  bent  forward,  head  hanging,  limbs 
partially  flexed  (if  standing), — all  of  which  accords  with 
the  facial  expression  of  sadness  and  despair — brow  con- 
tracted, corners  of  mouth  depressed,  muscles  of  face  relaxed, 
eyes  partially  closed  and  dull.  In  maniacal  conditions  the 
attitudes  assumed  are  energetic  and  the  play  of  the  features 
is  very  lively,  while  the  eyes  are  bright  and  all  the  face  indi- 
cates the  quick  play  of  feeling  (pleasant  or  angry). 

In  some  cases  of  hallucination,  are  observed  the  attitude 
and  facial  expression  of  fear  and  expectation ;  in  others,  those 
of  fixed  attention ;  in  others,  there  is  the  fixed  attention  and 
expression  of  beatitude  or  of  worship  (ecstacy). 

In  contrast  with  the  foregoing,  is  the  facial  expression 
of  dementia, — absence  of  feeling;  mouth  open,  with  an  at- 


DISORDERED  ACTS.— THE  WILL.  57 

titude  of  relaxation  which  may  be  much  like  that  of  melan- 
cholia. 

The  disorders  oe  speech  observed  in  insanity  are  nu- 
merous. Many  insane  persons  do  not  speak  at  all,  and  it  may 
be  difficult  to  determine  the  cause  of  this.  Aside  from  that  of 
idiocy,  it  is  found  that  insane  mutism  is  the  result  of  hallu- 
cinations or  delusions.  Hysteric  mutism  is  a  special  form 
of  this  disorder. 

Insane  patients  that  speak  may  present  disorders  of 
speech  due  to  the  fundamental  mental  disturbance  (coprol- 
alia). Mental  confusion  or  incoherence  expresses  itself  in  an 
incoherence  of  language,  a  mixing  of  words  without  order  or 
meaning ;  or  language  may  become  simply  a  series  of  words, 
one  suggesting  another  by  assonance, — a  lesser  degree  of 
which  is  rhyming. 

The  formation  of  new  or  senseless  words  to  indicate  de- 
lusional ideas  is  very  common  in  some  forms  of  mental  dis- 
ease. 

Verbigeration  is  a  term  applied  to  the  constant  repeti- 
tion of  the  same  word  or  phrase. 

Echo-speech  is  the  repetition  of  what  is  heard,  as  if  it 
took  place  reflexly. 

Certain  patients  speak  with  great  rapidity — a  true 
logorrhoea.  In  contrast,  is  great  slowness  of  speech,  words 
being  separated  by  long  intervals. 

Stuttering  and  stammering  can  only  have  significance 
if  they  begin  during  the  psychosis. 

The  tone  of  the  voice  also  presents  anomalies.  It  may 
be  low,  whispering,  tremulous,  loud  or  harsh ;  in  organic  psy- 
choses the  voice  may  be  nasal,  or  present  other  peculiarities 
due  to  paralysis  of  the  organs  of  articulation. 

By  far  the  most  important  disturbance  of  speech  in  in- 


58  OUTLINES   OF   PSYCHIATRY. 

sanity  is  the  defect  of  articulation  observed  in  paretic  demen- 
tia. It  is  characterized  by  a  stumbling  on  syllables  and  an 
impossibility  of  pronouncing  certain  syllables,  which  in  its 
highest  degree  renders  certain  words  unintelligible.  The 
speech  of  paretic  dementia  is  fully  considered  in  the  descrip- 
tion of  that  disease. 

The  hand-writing  of  the  insane,  in  form  and  content, 
presents  anomalies  allied  to  those  of  speech.  With  perfec- 
tion of  form,  written  language  betrays  the  peculiarities  of 
ideas  or  feelings  revealed  by  speech ;  but  at  times  the  insane 
may  be  silent  or  reserved  in  speech  and  very  communicative 
in  writing.  Certain  patients  are  given  to  underlining  some 
words  or  certain  phrases,  or  to  making  new  words.  Coprola- 
lia has  also  its  equivalent  in  writing,  in  the  sense  that  the 
patient  cannot  put  pen  to  paper  without  writing  something 
disgusting  or  obscene,  usually  a  phrase  repeated  until  the 
paper  is  full  and  crisscrossed.  Extremely  fine  (small)  writ- 
ing may  be  a  peculiarity. 

The  handwriting  of  the  maniacal  is  careless  and  imper- 
fect in  form,  and  shows  the  superficial  character  of  the  asso- 
ciation of  ideas. 

In  paretic  dementia  the  writing  is  tremulous,  and  shows 
absence  of  letters  or  syllables  comparable  to  the  defects  of 
speech  observed  in  that  disease. 

Mirror  writing  is  a  rare  phenomenon.  The  writing- 
is  from  right  to  left  and  requires  its  reflection  in  a  mirror 
to  make  it  legible ;  for  it  is  exactly  the  opposite  in  movement 

and  form  of  normal  writing. 

******** 

The  physical  accompaniments  op  insanity.  In 
the  vast  majority  of  cases,  insanity  is  a  sign  of  imperfect 
constitution   or  development ;  and  logically  we  might   ex- 


DISORDERED  ACTS.— THE  WILL.  59 

pect  to  find  associated  with  it  physical  imperfections. 
Observation  shows  that  certain  physical  defects  are  more 
common  in  the  insane  than  in  the  sane.  Such  defects  of 
physical  development,  marked  deviations  from  the  average 
of  form  and  constitution  of  parts  or  of  the  organism  as  a 
whole,  are  called  physical  signs  of  degeneracy.  However,  it 
must  be  emphasized  at  once  that  there  is  no  absolutely  neces- 
sary connection  between  physical  signs  of  degeneracy  and  in- 
sanity. A  sound  mind  may  exist  in  a  very  "degenerate" 
body,  and  a  "degenerate"  mind  may  control  a  very  perfect 
body.  The  relation  of  physical  and  mental  degeneracy  is 
one  of  averages.  Physical  degeneracy  is  more  common  in 
the  insane  than  in  the  sane;  and  there  it  is  more  marked  in 
association  with  certain  forms  of  mental  disease  that  are 
called  degenerate.  The  combination  of  the  two  is  called 
psycho-physical  degeneracy. 

The  so-called  physical  signs  of  degeneracy  consist  of 
physical  defects  which  place  the  individual  below  the  ideal 
average  of  physical  development. 

The  cranium  in  size  and  form  is  first  to  consider  from  a 
clinical  standpoint.  (Degenerate  morphology  of  the  brain 
can  only  be  determined  post-mortem.)  A  head  too  large  or 
too  small  can  be  readily  recognized,  but  it  is  better  to  be  pre- 
cise. Observation  has  determined  averages  of  size  which 
are  normal.  Certain  measurements  are  used  to  determine 
the  size  and  form  of  the  head  of  the  living.  The  following 
are  averages  for  the  living  adult : 

Circumference— average— male,  541  millimeters;  female,  523  mil- 
limeters. 

A  circumference  of  550  mm.  or  more  is  called  megalocephaly;  one 
of  461  mm.  or  less  is  called  microcephaly. 

Length— average — male,  183  mm.;  female,  178  mm. 

Breadth— average— male,  150  mm.;  female,  140  mm. 


60  OUTLINES   OF   PSYCHIATRY. 

The  breadth  index  is  obtained  by  dividing  the  breadth,  multiplied 
by  100,  by  the  length.     (™) 

75  or  less  is  called  dolichocephaly. 

75-80  is  called  mesocephaly. 

80-85  is  called  brachycephaly. 

The  facial  angle  is  determined  by  the  angle  formed  by  the  profile 
line  and  the  horizontal  plane  of  the  skull  (auriculo-nasal  line). 
When  this  angle  is  82  degrees  or  less,  the  skull  is  prognathous; 
mesognathous  when  it  is  from  83  to  90  degrees ;  hyperorthognathous 
when  it  is  90  degrees  or  more. 

The  hydrocephalic  head  is  characterized  by  over-devel- 
opment of  the  skull  with  arrest  of  development  of  the  face. 

Cretinism  presents  certain  cranial  forms  more  or  less 
characteristic. 

Inequalities  and  asymmetries  of  the  skull  are  important 
only  when  very  marked;  for  defect  at  one  point  or  on  one 
side  is  usually  compensated  by  over-development  elsewhere. 

The  numerous  classes  of  skulls  distinguished  in  craniol- 
ogy  have  but  a  subordinate  practical  interest  for  the  alienist. 

The  malformations  of  the  hard  palate  and  the  dental 
arches  have  been  very  elaborately  studied.  Want  of  union 
of  the  hard  and  soft  palates,  and  the  high  and  narrow  pala- 
tal arch,  are  the  most  common.  The  dental  arch  may  show 
unilateral  or  bilateral  defect  or  distortion.  Many  of  these 
defects  are  due  to  loss  of  teeth  during  the  years  of  develop- 
ment ;  others  are  due  to  defects  of  development  of  the  supe- 
rior maxillary  bones  and  the  nares. 

The  teeth  present  anomalies  in  number,  form,  and  size. 
The  Hutchinsonian  teeth  (upper  incisors, — hereditary  syphi- 
lis) have  the  form  of  a  "screw-driver." 

Malformations  of  the  ears  are  extremely  common,  and 
many  have  been  described :  unequal  size  or  difference  of 
form ;  unlike  implantation ;  defect  of  parts  like  the  lobule ; 
attachment  of  the  lobule  to  the  skin  of  the  face.     The  Dar- 


DISORDERED  ACTS.— THE  WILL.  61 

winian  ear  is  characterized  by  a  prominent  point  on  the 
outer  and  upper  portion  of  the  helix  (Faune's  ear).  Morel's 
ear  is  one  very  large  and  flat  (wing-like)  in  its  upper  half. 

The  eyes  present  many  defects  of  position  (Mongolian) 
and  size,  as  well  as  various  peculiarities  in  form  and  color. 

In  the  limbs  are  observed  club-foot,  club-hand,  supernu- 
merary digits  or  want  of  digits,  and  also  union  of  adjacent 
fingers  and  toes. 

Certain  defects  in  the  growth  of  the  hair  are  also  to  be 
mentioned :  deficiency  of  growth  or  overgrowth ;  growth  in 
unusual  places,  like  the  tuft  of  hair  of  mythologic  satyrs 
over  the  lumbar  portion  of  the  vertebral  column.  This  pecu- 
liar growth  of  hair  is  possibly  less  frequent  now  than  for- 
merly; or  our  habits  and  dress  cause  it  to  seem  so.  Sutton 
explains  it  as  due  to  spina  bifida ;  for  defective  closure  of  the 
vertebral  canal  is  usually  attended  by  growth  of  coarse 
hair  on  the  skin  that  lies  over  the  opening. 

The  various  genital  defects  are  also  important :  hypos- 
padiasis,  epispadiasis.  cryptorchism,  enormous  clitoris,  im- 
perforate hymen  or  vagina,  uterus-bicornus,  etc. 

These  physical  signs  of  degeneracy  are  very  common  in 
the  sane.  If  many  or  several  of  them  be  present  in  one  per- 
son we  are  perhaps  justified  in  speaking  of  physical  degen- 
eracy; but  one  or  a  few  such  signs  would  not  permit  us  to 
conclude  that  an  individual  is  degenerate.  As  far  as  the 
mind  is  concerned  they  have  no  positive  individual  value  ex- 
cept in  cases  of  very  gross  imperfection  of  development  of 
the  body  and  the  cranium.  The  only  practical  criterion  of 
the  conditon  of  the  mind  lies  in  the  mental  manifestations. 

However,  physical  signs  of  degeneracy  are  more  fre- 
quently observed  in  the  mentally  defective  and  the  insane 
than  in  the  population  at  large ;  and  the  physical  signs  of 


62  OUTLINES   OF   PSYCHIATRY. 

degeneracy  are  very  frequently  associated  with  certain  forms 
of  mental  anomalies  which  are  called  signs  of  psychic  de- 
generacy. Thus  there  are  certain  cases  of  insanity  or  mental 
defect  called  instances  of  psycho-physical  degeneracy.  In 
other  cases  the  same  mental  symptoms  without  physical  signs 
of  degeneration  are  spoken  of  as  examples  of  psychic  degen- 
eracy; thus  a  class  of  degenerate  insanity  is  established. 

The  physical  and  mental  signs  of  degeneracy,  as  a  rule, 
are  indications  of  a  bad  heredity,  which  as  an  element  in  the 
causation  of  insanity  takes  the  first  rank. 

The  practical  value  and  importance  of  physical  and  men- 
tal signs  of  degeneracy  will  be  clear  in  the  study  of  the 
etiology  of  insanity,  and  in  the  description  of  the  various 
forms  of  mental  disease  and  mental  defect. 


LESSON  IX. 

Anomalies    op    General    Bodily    Functions;     Some 
Special  Nervous  Signs  and  Symptoms. 

Insanity  is  essentially  a  symptomatic  expression  of  dis- 
turbance of  the  cerebral  cortex  and  the  nervous  system.  The 
underlying  cerebral  and  nervous  disturbance  may  be  organic 
or  functional ;  that  is,  due  to  material  alterations  of  nerve- 
tissue  or  to  conditions  that  leave  no  material  trace  behind. 
In  certain  cases  the  mental  symptoms  can  be  interpreted  as 
certainly  the  expression  of  organic  disease;  in  others  we  can 
not  postulate  more  than  a  derangement  of  activities  of  nerve- 
centers.  For  the  most  part  insanity  on  an  organic  basis  is 
incurable,  while  many  cases  of  insanity  of  a  functional  kind 
may  terminate  in  "recovery."  Therein  lies  the  importance 
of  correct  diagnosis  with  reference  to  the  organic  or  func- 
tional nature  of  a  given  case.  This  is  the  first  question  to 
consider  in  the  diagnosis  of  insanity,  as  in  nervous  diseases 
in  general,  and  should  be  the  starting  point  of  the  examina- 
tion. 

The  immediate  mental  symptoms  may  enable  us  to  de- 
termine the  existence  of  an  insane  state,  but  they  may  offer 
only  presumptive  evidence  of  the  organic  or  functional  na- 
ture of  the  underlying  cerebral  condition.  For  this  reason 
physical  indications  of  organic  disease  of  the  brain  or  nerv- 
ous system  are  of  capital  importance  as  an  index  of  the  prob- 

63 


64  OUTLINES  OF    PSYCHIATRY. 

able  nature  of  accompanying  mental  derangement.  How- 
ever, it  must  be  emphasized  that  there  is  no  necessary  con- 
nection or  relation  between  signs  of  organic  nervous  disease 
and  insanity.  For  example,  an  organic  hemiplegic  may  be 
insane  or  not;  there  may  be  direct  relation  between  the 
paralysis  and  insanity  or  not.  A  hemiplegic  may  have  an 
attack  of  melancholia  and  recover  like  any  other  person.  An 
aged  person  showing  the  natural  mental  signs  of  age — dull- 
ing of  the  mental  faculties  and  living  in  tempora  acta — may 
have  and  recover  from  an  attack  of  functional  insanity. 

Physical  symptoms  that  accompany  insanity  do  not  nec- 
essarily form  a  part  of  the  insanity ;  for  these  symptoms  are 
met  every  day  in  sane  persons,  and  they  are  wanting  in  some 
cases  of  insanity  at  all  times,  in  others,  at  certain  periods  of 
the  disease.  In  general  it  may  be  said  that  all  acute  insani- 
ties present  many  symptoms  of  derangement  of  bodily  func- 
tions; that  chronic  insanities  may  or  may  not,  according  to 
their  nature,  present  such  symptoms. 

Sleep  as  a  general  vital  phenomenon  presents  many 
anomalies  in  insanity,  especially  in  acute  cases ;  but  it  may  be 
perfectly  normal  in  insanity.  Absolute  absence  of  sleep 
(agrypnia)  is  observed;  insomnia,  or  only  fitful  and  tem- 
porary sleep,  is  a  symptom  seen  in  certain  cases.  Agrypnia 
and  somnolence  may  be  of  indefinite  duration.  The  natural 
time  for  sleep  may  be  altered :  wakefulness  at  night,  som- 
nolence during  the  day.  Narcolepsy  is  a  peculiar  phenome- 
non in  which  sleep  overcomes  the  patient  suddenly  and  with- 
out warning — like  an  epileptic  attack — and  which  ends  spon- 
taneously with  no  necessary  relation  to  efforts  made  to 
arouse  the  patient. 

The  temperature  is  for  the  most  part  normal  in  in- 
sanity.    Any  marked  rise  or  fall  calls  for  a  search  for  its 


ANOMALIES  OF  GENERAL  BODILY  FUNCTIONS.  65 

physical  cause  as  in  any  other  case  of  disease.  There  are 
important  exceptions  to  this  statement;  namely,  in  acute 
delirious  mania  (probably  an  infection),  and  in  the  cerebral 
attacks  that  occur  in  the  course  of  paretic  dementia.  Sub- 
normal temperatures  and  rapid  or  daily  variations  of  tem- 
perature are  observed  in  chronic  insanities,  but  in  such  cases 
they  probably  depend  on  infections   (tuberculosis). 

The  pulse  is  very  frequently  normal,  but  it  may  present 
many  abnormalities.  As  a  rule,  in  states  of  excitement  it  is 
rapid  and  full ;  in  depression,  slow  and  hard ;  in  organic 
cerebral  disease  it  follows  the  usual  law, — slow  in  apoplexy 
and  in  cases  of  cerebral  tumor.  The  blood  pressure  corre- 
sponds with  these  conditions, — lowered  in  maniacal,  in- 
creased in  melancholic  conditions. 

Respiration  is  altered,  especially  in  melancholia  and 
marked  dementia, — it  becomes  slow  and  superficial.  It  may 
be  rapid  in  mania,  and  also  in  certain  states  of  mental  appre- 
hension. Aside  from  these  peculiarities  its  alterations  de- 
pend upon  physical  complications  (infections,  gross  cere- 
bral and  bulbar  lesions). 

The  Functions  OF  THE  alimentary  Tract  are  fre- 
quently deranged  in  the  initial  and  acute  stages  of  insanity — 
loss  of  appetite,  constipation,  foul  tongue,  etc.  Food  may 
be  absolutely  refused  because  of  such  conditions;  but  very 
frequently  refusal  of  food  has  a  delusional  cause,  aside  from 
any  existing  derangement  of  the  digestive  organs.  The  odor 
of  the  breath  of  a  patient  that  does  not  take  food  soon  be- 
comes peculiar, — it  is  somewhat  like  that  of  ether ;  this  is 
said  to  be  due  to  the  presence  of  acetone.  Increase  of  appe- 
tite with  loss  of  the  sense  of  satiety  is  characteristic  of  de- 
mentia. 

General  nutrition    (weight)    shows  very  important 


66  OUTLINES  OF    PSYCHIATRY. 

variations  that  are  connected  directly  with  the  mental  state. 
Independently  of  the  appetite  and  the  amount  of  food  taken, 
in  the  acute  insanities  there  is  loss  of  weight;  the  depressed 
and  the  excited  alike  grow  thin.  Increase  of  weight  after 
loss,  if  it  correspond  with  abatement  of  mental  symptoms, 
is  of  favorable  omen ;  but  it  marks  the  beginning  of  chronic 
mental  weakness  if  it  occur  without  signs  of  mental  im- 
provement. 

Special  trophic  anomalies  are  often  observed  in  or- 
ganic insanity — paretic  dementia,  chronic  dementia.  The 
insane  ear  (othematoma)  is  especially  remarkable.  It  re- 
sults from  hemorrhage  between  the  cartilage  and  the  epi- 
chondrium,  usually  caused  by  a  blow  or  other  mechanical  in- 
jury to  the  ear.  The  insignificance  of  the  injury  seems 
to  prove  that  the  resulting  hemorrhage  is  favored  by  trophic 
changes  in  the  vessels  of  the  epichondrium.  The  swelling 
usually  occupies  a  position  on  the  internal  surface  of  the 
concha  or  helix ;  it  may  be  very  small  at  first  and  gradually 
increase  till  the  ear  is  filled  by  a  fluctuating  swelling  more 
or  less  bluish  in  color.  Finally  the  effusion  is  absorbed  with 
consequent  cicatricial  distortion  of  the  ear.  Similar  swell- 
ings occur  elsewhere  (cartilage  of  nose,  ribs,  etc.).  Othe- 
matoma occurs  in  sane  persons  (pugilists). 

Abnormal  fragility  of  bones  is  seen  in  paretic  de- 
mentia. 

Decubitus  (bed  sores)  and  mal  perforans,  due  to  tro- 
phic changes  in  the  subcutaneous  tissues,  are  frequent  in 
bedridden  patients.  Uncleanliness  often  acts  as  an  exciting 
cause;  but  there  are  very  acute  cases  which  must  depend  on 
trophic  changes  alone. 

Trophic  changes  of  the  hair,  nails,  and  teeth  are  not  in- 
frequent in  organic  insanity. 


ANOMALIES  OF  GENERAL  BODILY  FUNCTIONS.  67 

Disturbance  of  the  vasomotor  functions  is  very 
common — vascular  spasm  or  paralysis. 

The  secretions  are  frequently  disordered.  The  secre- 
tion of  saliva  is  increased  in  certain  cases  (maniacal),  di- 
minished in  others  (depression).  The  lacrymal  secretion  is 
frequently  deficient  or  wanting  in  melancholia.  Perspira- 
tion may  be  excessive  or  entirely  wanting-;  or  these  anom- 
alies may  be  partial  or  localized. 

The  urine  presents  many  anomalies:  diminution  of 
phosphoric  acid;  albumen;  sugar,  etc.  The  practical  im- 
portance of  these  is  the  same  as  in  cases  of  physical  disease. 

The  disorders  of  the  functions  of  the  bladder 
and  rectum  deserve  careful  consderation,  for  they  are 
extremely  frequent  in  insanity.  Incontinence  of  urine  may 
be  due  to  lack  of  attention  (pre-occupation),  and  the  urine 
is  passed  reflexly;  or  to  absence  of  the  normal  feeling  of 
distention  of  the  bladder.  It  occurs  reflexly  in  states  of 
unconsciousness ;  it  may  be  due  to  paralysis  of  the  sphincter. 
Some  patients  pass  urine  purposely  with  a  view  to  give  the 
impression  of  enuresis.  Retention  of  urine  may  arise  from 
inattention  with  simultaneous  spasm  of  the  sphincter,  or  from 
anesthesia  of  the  bladder.  It  may  be  due  to  paralysis  of  the 
detrusor  or  loss  of  the  reflex,  as  observed  in  organic  disease 
of  the  brain  and  spinal  cord.  Some  patients  purposely  retain 
the  urine  to  induce  genital  manipulation  (females).  Drib- 
bling of  urine  may  be  an  indication  of  incontinence  or  of  re- 
tention, and  always  requires  careful  examination  of  the 
bladder.  In  general,  depressed,  stuporous,  and  unconscious 
patients  should  be  examined  with  special  care  for  anomalies 
of  the  functions  of  the  bladder. 

Incontinence  of  feces  may  have  causes  like  those  of 
enuresis.     The  retention  of  feces,  aside  from  spontaneous 


68  OUTLINES  OF   PSYCHIATRY. 

constipation,  may  be  intentional  and  due  to  delusions.  Over 
distention  of  the  rectum  occurs  and  may  require  mechanical 
interference.  Some  patients  intentionally  soil  themselves, 
their  beds,  and  their  surroundings  with  feces  and  urine  in 
obedience  to  delusions. 

Menstruation  presents  many  variations.  It  may  be 
undisturbed,  irregular,  or  entirely  absent.  Its  return  during 
the  course  of  an  acute  functional  psychosis  has  the  same 
significance  as  gain  in  weight;  if  it  occur  simultaneously 
with  mental  improvement  it  is  a  favorable  sign. 

Physical  diseases  are  very  frequently  associated  with 
insanity.  Their  relation  to  mental  diseases  may  be  intimate 
or  remote;  they  may  be  direct  or  indirect  etiologic  factors. 
They  are  not  symptomatic  of  insanity,  but  they  may  exercise 
a  profound  influence  on  the  insane  symptoms.  The  discus- 
sion of  these  relations  will  be  best  understood  in  connection 

with  the  etiology  of  insanity. 

********* 

Special  nervous  signs  and  symptoms  associated  with 
insanity  are  of  the  first  importance  as  making  possible  the 
fundamental  distinction  of  organic  disease  of  the  nervous 
system  from  functional  neuro-psychic  disturbances. 

The  association  of  organic  disease  of  the  nervous  system 
and  insanity  is  in  the  great  majority  of  such  cases  that  of 
organic  relation ;  the  possible  exceptions  are  rare.  For  this 
reason  the  neurologic  examination  of  an  insane  patient  is 
as  necessary  as  the  psychologic. 

The  diagnostician  of  nervous  disease  is  logically  forced 
to  say  in  the  absence  of  signs  of  organic  disease  that  the  case 
is  presumably  functional ;  for  if  organic,  it  cannot  positively 
be  declared  organic;  nor  can  it  positively  be  declared  to  be 
functional. 


ANOMALIES  OF  GENERAL  BODILY  FUNCTIONS.  69 

The  reflexes  of  the  nervous  system  allow  a  very  complete 
examination  of  its  organic  condition,  and  enable  us  to  speak 
with  comparative  certainty  of  the  nature  of  symptoms  pre- 
sented. Objective  signs  of  disease  form  the  soundest  basis 
for  correct  diagnosis  and  the  state  of  the  reflexes  affords  us 
this  objective  evidence. 

Functional  nervous  and  mental  conditions  do  not 
disturb  or  ALTER  The  REFLEXES.  This  statement  is  not 
in  accord  with  that  of  the  majority  of  authors.  But  it  is 
practically  nearer  the  truth  than  any  statement  to  the  con- 
trary; for  exceptions  to  it  are  extremely  rare,  if  they  exist, 
and  should  be  neglected  for  practical  purposes.  On  the 
other  hand  normal  reflexes  do  not  exclude  organic  nervous 
and  mental  disease. 

Examination  of  the  fundus  of  the  eye  gives  us  some 
data.  Optic  nerve  atrophy  is  frequently  but  a  local  mani- 
festation of  more  general  organic  disease  of  the  nervous 
system;  choked  disk  is  a  frequent  accompaniment  of  intra- 
cranial growths. 

The  latest,  and  a  very  valuable,  addition  to  our  means  of 
nervous  diagnosis  is  examination  of  the  cerebrospinal  fluid, 
obtained  readily  and  without  special  danger  by  lumbar  punc- 
ture. It  is  precisely  in  certain  doubtful  cases  of  insanity 
that  it  gives  the  greatest  aid. 

There  are  certain  forms  of  anesthesia  (hypesthesia) 
which  are  positively  indicative  of  organic  nervous  disease; 
but  anesthesia  is  a  subjective  symptom,  the  nature  and  limits 
of  which  are  often  difficult  to  establish,  especially  in  connec- 
tion with  insanity. 

Paralyses,  muscular  atrophies,  and  certain  other  func- 
tional losses,  may  indicate  organic  nervous  disease ;  but  they 
require  control,  for  they  are  not  unequivocal.    Thus  paraly- 


70  OUTLINES  OF   PSYCHIATRY. 

sis  may  be  indicative  of  functional  or  organic  disease,  and 
it  requires  the  aid  of  other  signs  to  determine  its  true  signifi- 
cance.   The  same  may  be  said  of  muscular  atrophy. 

Profound  trophic  disturbances  that  lead  to  destructive 
changes  of  tissue  are,  as  a  rule,  signs  of  organic  nervous 
disease.  The  slight  and  transitory  vasomotor  anomalies  of 
insanity  have  not  this  significance. 

Though,  as  a  rule,  organic  diseases  of  the  nervous  sys- 
tem are  incurable,  this  is  not  a  law;  there  are  notable  ex- 
ceptions, in  the  sense  that  complete  restoration  of  functions 
occurs  with  disappearance  of  all  positive  signs  of  organic 
disease.  In  such  cases  we  may  assume  clinically  that  nerve- 
tissue  escaped  complete  destruction ;  or  that  the  function  of 
an  injured  or  destroyed  portion  of  the  nervous  system  has 
been  assumed  by  another  portion.  Restoration  of  function 
by  this  means  is  the  only  logical  explanation  of  certain  path- 
ologic findings. 


LESSON  X. 

Some  Signs  and  Symptoms  of  Organic  Nervous  Dis- 
ease.—  ( Continued. ) 

The  STATE  of  the  reflexes  affords  the  best  evidence  of 
the  condition  of  the  nervous  system  and  they  deserve  to  be 
considered  first. 

The  reflexes  are  not  disturbed  in  insanity;  for  insanity 
is  purely  an  anomaly  of  mentality,  and  the  reflexes  are  or- 
ganic functions  fundamentally  independent  of  the  mind, 
though  still  subordinate  to  it  within  certain  limits.  The  re- 
flex mechanism  that  controls  the  bladder  is  to  a  certain  de- 
gree subordinate  to  the  will :  we  can  restrain  the  organic 
reflex  impulse  to  empty  the  bladder ;  but  in  states  of  uncon- 
sciousness the  reflex  mechanism  acts  independently.  Volun- 
tary restraint  does  not  annihilate  the  reflex,  which  is  con- 
stantly seeking  to  bring  about  a  certain  act;  it  opposes  a 
voluntary  contraction  of  the  sphincter  of  the  bladder  more 
powerful  than  the  reflex  impulse  to  relax  it. 

Similarly  the  mental  state  may  inhibit  or  increase  the 
knee-jerk;  but  its  apparent  loss  or  increase  from  such  a 
cause  is  attended  by  other  signs  which  explain  the  seeming 
anomaly;  on  the  contrary,  organic  loss  of  the  knee-jerk  can- 
not be  overcome  voluntarily,  nor  can  the  revelation  of  or- 
ganic exaggeration  of  it  be  prevented  mentally.  The  volun- 
tary movement  made  to  imitate  the    knee-jerk    (observed 


71 


72  OUTLINES  OF    PSYCHIATRY. 

rarely  in  tabetics  anxious  to  deceive  themselves)  is  easily- 
recognized  as  such  by  the  long  interval  between  the  blow  and 
the  jerk;  the  voluntary  effort  to  control  an  exaggerated 
knee-jerk  may  limit  the  movement,  but  causes  an  exagger- 
ated subsequent  recoil. 

The  same  is  true  of  the  skin  or  superficial  reflexes.  In 
hysteria  there  is  often  absence  of  sensibility  of  the  conjunc- 
tiva and  cornea,  and  the  eyelids  do  not  move  when  the  con- 
junctiva is  touched.  In  such  cases  the  insensibility  is  mental 
(virtual),  with  a  possible  element  of  restraint  of  winking  (as 
in  the  example  of  the  bladder) .  The  justice  of  this  assump- 
tion is  proved  by  the  fact  that  in  such  a  case  the  conjunctiva 
is  constantly  cleaned  and  protected  by  the  automatic  move- 
ments of  the  eyelids ;  the  reflex  exists  but  is  restrained  for 
certain  stimuli.  Moreover,  organic  insensibility  of  the  con- 
junctiva leads  very  soon  to  serious  trouble  in  the  con- 
junctiva and  cornea,  because  the  organic  reflex  is  really  lost, 
not  restrained.  The  occasional  loss  of  other  superficial  re- 
flexes in  hysteria  may  be  explained  in  the  same  way. 

Pathologic  alterations  of  the  deep  or  tendon-reflexes 
indicate  organic  disease  of  the  nervous  system.  The  tendon- 
jerks  are  always  present  in  health ;  the  instances  found  in  lit- 
erature of  absence  of  certain  tendon-reflexes  in  normal  per- 
sons are  so  rare  and  so  open  to  doubt  about  the  cause  of 
absence,  that  they  should  be  ignored.  The  tendon-jerks  are 
practically  never  alike  in  force  and  extent  of  movement  in 
any  two  persons,  and  they  vary  normally  within  wide  limits 
at  various  times  in  the  same  person.  This  normal  variation 
causes  much  confusion  in  estimating  them,  and  thus  in  the 
text-books  lively  reflexes  are  called  plus  and  moderate  re- 
flexes minus,  with  the  implication  that  these  qualities  are 
pathologic.    The  fact  is  that  in  estimating  the  quality  of  the 


SYMPTOMS  OF  ORGANIC  NERVOUS  DISEASE.  73 

tendon-reflexes  the  greatest  care  is  necessary.  The  reflex 
movement  may  be  such  that  no  conclusion  can  be  drawn 
from  it.  A  very  lively  or  a  slight  reflex  movement  may  be 
perfectly  normal.  Absence  of  deep  reflexes  is  always  a  sign 
of  disease.  Lively  reflexes  to  be  signs  of  disease,  must  pre- 
sent certain  qualities  or  certain  accompaniments  which  make 
it  clear  that  they  are  exaggerated  as  a  result  of  disease. 

The  reflexes  to  be  discussed  here  are  those  that  should 
be  examined  as  a  matter  of  routine  as  having  a  possible  bear- 
ing on  the  condition  of  the  brain. 

The  iris  (1)  moves,  dilates  or  contracts  the  pupil,  in 
obedience  to  the  stimulus  of  light  and  in  the  act  of  accommo- 
dation ;  the  first  is  a  reflex  to  light ;  the  second  is  an  associated 
movement.  The  iris  moves  also  in  certain  emotional  mental 
states  and  in  convergence.  Fear  is  attended  by  dilatation  of 
the  pupils.  Narrowing  of  the  pupils  is  due  to  contraction  of 
constricting,  widening  to  contraction  of  the  dilating  muscles 
of  the  iris.  Branches  of  the  third  nerve  supply  the  con- 
strictors ;  nerves  from  the  medulla,  reaching  the  iris  through 
the  sympathetic,  supply  the  dilators.  Besides  these  sources  of 
direct  innervation,  doubtless  the  size  of  the  pupil  and  the 
movements  of  the  iris  are  influenced  by  the  vascular  condi- 
tion of  the  iris,  and  possibly  the  latter  is  the  connecting  link 
between  an  emotion  like  fear  and  dilatation  of  the  pupil ;  and 
the  contraction  or  dilatation  of  the  pupils  in  certain  tempo- 
rary states  of  loss  of  consciousness  (syncopic,  epileptic, 
apoplectic)  possibly  may  be  due  to  the  same  cause.  Probably 
the  size  of  the  pupil  depends,  when  innervation  and  all  other 
conditions  are  normal,  upon  the  vascular  condition  of  the 
iris. 


1  The  effect  of  poisons  to  alter  the  reflex  movements  of  the  iris  is  not 
discussed. 


74  OUTLINES  OF    PSYCHIATRY. 

The  pupil  dilates  when  the  skin  of  the  neck  is  painfully- 
irritated  (pricked,  pinched).  This  is  said  to  be  due  to  stimu- 
lation of  the  sympathetic ;  it  may  be  due  to  a  vascular  influ- 
ence, for  pain  in  general,  like  fear,  causes  pupillary  dilata- 
tion and  at  the  same  time  constriction  of  the  superficial  and 
smaller  bloodvessels  (pallor).  It  may  be  noted  in  passing 
that  morphine,  which  contracts  the  pupil,  is  a  vasodilator; 
that  belladonna,  a  mydriatic,  is  a  vascular  antagonist  of  mor- 
phine. 

Normally,  whatever  be  the  size  of  the  pupil  resulting 
from  its  vascular  condition,  it  may  be  modified  by  light  and 
by  the  effort  of  accommodation. 

When  light  is  thrown  on  the  retina  the  pupil  becomes 
smaller,  to  return  to  its  former  size  when  the  stimulus  is 
removed :  this  is  the  reflex  to  light.  The  pupil  also  grows 
smaller  when  an  effort  is  made  to  accommodate  for  a  near 
object;  this  is  an  "associated  movement"  of  the  iris  in  re- 
lation with  the  movement  of  convergence  and  contraction 
of  the  ciliary  body ;  and  it  may  occur  in  the  absence  of  con- 
vergence in  the  effort  of  accommodation.  There  is  a  psychic 
contraction  of  the  pupil  which  is  probably  of  the  same  nature 
as  the  movement  in  accommodation,  and  the  result  of  at- 
tention and  expectancy  of  need  to  accommodate. 

The  movements  of  the  two  pupils  are  co-ordinate,  and 
yet  independent.  Normally  they  always  move  in  the  same 
sense  together,  and  maintain  the  same  size.  When  the 
stimulus  (light)  affects  one  retina  more  than  the  other, 
both  pupils  contract,  but  the  contraction  is  most  marked  in 
the  eye  receiving  the  greater  stimulus.  When  one  eye  is 
kept  in  darkness  its  pupil  dilates  widely ;  the  exposed  pupil 
also  dilates,  but  less  markedly.    These  correlated  movements 


SYMPTOMS  OF  ORGANIC  NERVOUS  DISEASE.  75 

of  the  pupils  are  called  "consensual  reaction."  The  varia- 
tions of  consensual  reaction  are  important  means  of  deter- 
mining the  seat  of  lesions  affecting  the  optic  nerve  and  the 
branches  of  the  third  nerve  distributed  to  the  iris.  To  give 
an  example  of  its  importance:  if  the  left  optic  nerve  be  com- 
pletely atrophied  there  is  no  centripetal  conduction  and  a 
light  thrown  on  the  left  pupil  causes  no  change  in  the  size  of 
either  pupil ;  on  the  contrary,  if  the  right  retina  be  stimu- 
lated the  right  pupil  contracts  and  the  left  also,  though  less 
markedly,  if  the  efferent  path  through  the  third  nerve  be 
intact ;  and  the  left  pupil  also  acts  in  accommodation  with  its 
fellow.  Again,  if  the  efferent  conduction  in  the  left  third 
nerve  be  suspended  with  an  intact  left  optic  nerve,  stimula- 
tion of  the  left  retina  causes  no  contraction  of  the  left  pupil 
but  causes  contraction  of  the  right  pupil.  Thus,  loss  of  con- 
sensual reaction  may  be  due  to  lesion  of  one  optic  nerve  (loss 
in  the  sound  eye),  or  to  lesion  of  the  third  nerve  (loss  in 
the  affected  eye). 

The  Argyll-Robertson  pupil  is  one  that  moves  in 
accommodation  but  not  reflexly  to  light — a  pure  loss  of  re- 
flex movement  of  the  iris ;  it  may  affect  one  or  both  eyes. 
Consensual  reaction  is  not  lost  in  the  eye  presenting 
the  anomaly  if  it  be  due  to  optic  nerve  atrophy.  The 
Argyll-Robertson  pupil,  when  not  dependent  on  lesion  of 
the  eye  is  caused  by  lesion  in  a  special  reflex  arc  which  con- 
trols the  reflex  movement  of  the  iris,  probably  of  a  distinct 
reflex  center;  for  the  movement  of  the  iris  in  accommoda- 
tion remains  intact,  proving  that  the  efferent  path  (third 
nerve)  is  intact. 

Internal  ophthalmoplegia  is  paralysis  of  all  move- 
ments of  the  iris  and  of  the  ciliary  muscle — lack  of  accommo- 


76  OUTLINES  OF   PSYCHIATRY. 

dation,  of  the  movement  of  the  iris  to  light  and  in  the  effort 
of  accommodation;  so  that  vision  for  near  objects  is  defec- 
tive. It  is  not  uncommon  to  observe  iridoplegia — paralysis 
of  the  iris  for  reflex  and  accommodative  movement — with 
retention  of  the  power  of  accommodation.  Iridoplegia 
causes  a  fixed  pupil.  The  lesion  causing  it  must  be  of  the 
center  for  the  iris,  which  is  independent  of  the  center  for 
movement  of  the  ciliary  body. 

Simple  atrophy  of  one  optic  nerve  cannot  cause  an  Ar- 
gyll-Robertson pupil  in  the  strict  sense,  for  the  pupil  still  re- 
acts consensually  to  light  through  the  opposite  optic  nerve. 
Double  optic  nerve  atrophy  causes  fixed  pupils,  but  they 
still  react  to  painful  stimuli  (sympathetic-vascular),  and 
possibly  in  convergence. 

Slowness  oe  reaction  of  the  pupils  to  light  is  abnor- 
mal, and  often  the  initial  stage  in  the  development  of  the 
Argyll-Robertson  pupil. 

Unequal  pupils  may  exist  with  or  without  anomaly  of 
reaction  in  the  movement  of  the  two  pupils ;  usually  some 
abnormality  of  movement  will  be  discovered  in  one  or  the 
other  iris;  the  loss  of  movement  may  affect  the  smaller  or 
the  larger  pupil. 

Both  pupils  may  be  permanently  too  large  or  too  small, 
usually  with  an  abnormality  of  movement  of  the  irides.  So- 
called  pinhead  pupils  (spinal  myosis)  may  occur  in  tabes,  oc- 
casioned by  lesion  of  the  cord  at  the  level  of  the  first  and  sec- 
ond dorsal  segments,  whence  passes  by  the  communicating 
branch  to  the  sympathetic  the  nervous  influence  derived 
probably  from  the  medulla  which  actively  dilates  the  pupil. 
Argyll-Robertson  pupils  may  be  extremely  myotic ;  then  the 
movement  in  accommodation  is  comparatively  slight. 


SYMPTOMS  OF  ORGANIC  NERVOUS  DISEASE.  77 

Anomalies  of  the  pupil  as  they  occur  in  the  epileptic  state 
of  unconsciousness,  in  states  of  intoxication  or  temporary 
unconsciousness  from  any  cause,  are  temporary  and  devoid 
of  great  significance  for  the  differentiation  of  organic  cere- 
bral disease,  unless  taken  in  relation  to  other  signs  and  symp- 
toms of  organic  nervous  disease. 

Anomalies  of  the  pupils  of  a  permanent  kind,  existing  in- 
dependently of  any  disturbance  of  consciousness  and  of 
demonstrable  ocular  lesions,  are  almost  a  certain  indication 
of  organic  disease  of  the  nervous  system.  Associated  with 
insanity  they  are  likewise  practically  a  certain  sign  that  the 
insanity  has  an  organic  basis,  even  though  there  be  no  other 
sign  of  organic  cerebral  disease. 

The  true  Argyll-Robertson  pupil  is  almost  as  certainly  a 
sign  of  previous  syphilitic  infection  as  a  chancre  is  of  local 
infection.  It  may  indicate  as  well  hereditary  syphilis.  It 
is  observed  very  frequently  with  other  pupillary  anomalies 
due  to  syphilis,  especially  in  paretic  dementia. 

A  diagnosis  of  functional  insanity  should  never  be  made 
in  the  presence  of  an  anomaly  of  reaction  of  the  pupils,  unless 
the  anomaly  can  be  explained  by  local  conditions  in  the  eye 
demonstrably  without  relation  to  the  abnormal  mental  condi- 
tion. 

Paradoxical  reaction  of  the  pupil — dilatation  to  the  stim- 
ulus of  light — is  sometimes  observed,  a  stage  in  the  loss  of 
reaction  of  the  pupil  to  light. 

With  fixed  pupils  under  ordinary  conditions  of  observa- 
tion, sometimes  momentary  contraction  (associated  move- 
ment), can  be  induced  by  causing  the  patient  to  forcibly  close 
the  eyes  and  open  them  suddenly. 

The  pupils  should  be  examined,  in  case  of  suspected  an- 


78  OUTLINES  OF   PSYCHIATRY. 

omaly,  in  a  dark  room.  Comparison  of  suspected  pupils 
with  those  known  to  be  normal,  is  very  useful  as  a  guide, 
especially  for  the  detection  of  lazy  reaction,  which  may  be 
almost  as  important  as  an  actually  developed  Argyll-Rob- 
ertson pupil  as  an  aid  in  diagnosis. 

Senile  pupils  are  more  or  less  myotic  and  less  active  than 
those  of  younger  persons. 


LESSON  XL 
The  Deep  and  Superficial  ReeeExes. 

The  deep  reflexes  are  numerous  and  their  anomalies 
give  very  important  indications  of  organic  disease  of  the 
nervous  system. 

The  reflex  oE  the  TENdo  achillis  is  constant  in 
health ;  loss  or  exaggeration  of  it  is  a  sign  of  organic  disease. 
The  only  satisfactory  way  to  examine  it  is  with  the  patient 
kneeling  (either  in  a  chair  or  on  a  bed),  with  the  feet  and 
ankles  free  and  the  muscles  of  the  legs  in  a  state  of  complete 
relaxation.  With  the  limbs  thus  placed  a  tap  on  the  tendon 
wTill  show  the  presence  or  absence  of  the  ankle-jerk.  When 
present,  it  is  revealed  in  plantar  flexion  (extension)  of  the 
foot.  The  reflex  movement  must  not  be  confounded  with  the 
jar  or  jerk  communicated  to  the  foot  by  the  blow  of  the  ham- 
mer,—the  only  movement  noticeable  in  the  absence  of  the 
reflex. 

Exaggeration  of  the  ankle-jerk  is  not  so  easy  to  esti- 
mate, unless  the  blow  of  the  hammer  cause  a  clonic  move- 
ment, which  is  always  a  sign  of  organic  disease,  except  in 
cases  of  volitional  foot-clonus  the  characteristics  of  which 
are  hereafter  noted. 

The  best  means  of  estimating  exaggeration  of  the  ankle- 
jerk  is  the  presence  or  absence  of  foot-clonus.  To 
examine    for    it    the    limb    should     be     relaxed    and    the 

79 


80  OUTLINES  OF   PSYCHIATRY, 

knee     slightly     bent     and     supported     by     one     hand     of 
the    operator,    with    the    other    hand    the    foot    is    firm- 
ly    grasped      near     its     extremity      and      suddenly     and 
forcibly  brought  into  dorsal  flexion  and  there  maintained 
with  a  strain  that  is  not  too  forcible.     If  foot-clonus  be 
present,  the  foot  is  rhythmically  extended  and  flexed  by  al- 
ternate contraction  and  relaxation  of  the  muscles  attached 
to  the  tendo  Achillis,  and  this    vibratory    movement  may 
continue  as  long  as  the. upward  pressure  is  maintained;  or 
the  clonic  movement  may  gradually  die  away.     In  normal 
persons  when  this  maneuver  is  carried  out,  it  is  not  unusual 
to  observe  one  or  two  slow  movements  of  the  foot  in  exten- 
sion, but  they  have  no  rhythm  and  are  much  slower  than  the 
movements  of  true  foot-clonus.    A  person  may  imitate  foot- 
clonus  very  closely,  a  fact  which  makes  it  difficult  for  the 
beginner  to  interpret  the  sign.    Attention  to  certain  peculiar- 
ities overcomes  this  difficulty.     Commonly,  if  a  patient  be 
told  to  extend  the  foot  as  the  examiner  is  about  to  flex  it 
for  the  detection  of  foot-clonus  several  clonic  movements 
occur  closely  resembling  true  foot-clonus.     To  be  certain  of 
the  nature  of  these  movements  it  is  necessary  to  be  sure  that 
there  is  complete  relaxation  of  the  limb,  or  that  no  volun- 
tary contraction  of  the  posterior  muscles  of  the  leg  occurs  at 
the  moment  of  performing  the  manipulation.     As  a  further 
explanation  of  this  spurious  clonus  the  common  tremor  of 
the  foot  produced  at  will  may  be  cited.    If  one  raise  the  heel 
from  the  floor  (while  seated)  and  allow  the  weight  of  the 
limb  to  rest  on  the  ball  of  the  foot,  by  an  effort  of  the  will  a 
rhythmical  movement  of  the  limb  may  be  excited  due  to 
tremulous  contraction  of  the  posterior  muscles  of  the  leg — 
the  heel  dances  up  and  down.     Once  excited  this  movement 
may  continue  automatically  for  sometime  while  the  relative 


THE  DEEP  AND  SUPERFICIAL  REFLEXES.  81 

state  of  contraction  of  the  posterior  muscles  of  the  leg  is  con- 
tinued. However,  for  this  movement  there  must  be  also 
a  corresponding  activity  of  opposing  muscles  to  insure  the 
rhythm.  In  true  foot-clonus  the  upward  pressure  of  the  hand 
of  the  examiner  constitutes  the  opposing  force,  and  the  move- 
ment ceases  immediately  if  this  upward  pressure  is  removed. 
In  false  foot-clonus  as  observed  in  hysteria  and  functional 
conditions,  the  simultaneous  alternating  action  of  opposing 
muscles  causes  a  rhythmical  movement  of  the  foot  which  con- 
tinues after  the  initiating  upward  pressure  is  removed  (one 
of  my  patients  could  do  ii  with  either  foot,  but  not  with  both 
simultaneously,  as  he  naively  confessed,  after  his  voluntary 
clonus  had  been  regarded  by  several  observers  as  a  true 
foot-clonus).  True  foot-clonus  is  invariably  a  sign  of  ex- 
aggeration of  the  ankle- jerk  and  indicative  of  organic  dis- 
ease of  the  nervous  system.  It  never  occurs  in  hysteria, 
functional  disease,  or  fatigue. 

The  reflex  of  the  patellar  tendon  (knee-jerk)  is 
most  frequently  examined.  It,  like  the  ankle-jerk,  is  con- 
stant in  health.  Its  absence  is  always  indicative  of  organic 
nervous  disease;  its  exaggeration  has  also  the  same  signifi- 
cance. But  it  is  much  easier  to  determine  absence  of  the 
knee-jerk  than  exaggeration  of  it,  for  within  normal  limits, 
like  the  ankle- jerk,  it  presents  extreme  variations.  The  best 
position  for  examination  of  the  knee-jerk  is  that  of  flexion 
of  the  leg  on  the  thigh  at  a  very  obtuse  angle  (not  the  posi- 
tion of  flexion  at  right  angle,  with  the  leg  hanging  over  the 
edge  of  a  table,  as  almost  always  advised)  ;  the  patient  may 
be  seated  with  the  foot  on  the  floor.  The  blow  must  be  de- 
livered on  the  tendon  below  the  patella,  not  with  the  hand  or 
a  book,  but  with  a  proper  percussion  hammer  the  action  of 
which  can  be  judged  and  regulated.    The  weight  of  the  blow 


82  OUTLINES   OF   PSYCHIATRY. 

is  of  some  use  in  judging  the  character  of  the  reflex,  but  it 
lias  no  absolute  value;  for  normally  a  very  light  blow  may 
cause  a  very  lively  reflex  jerk.  At  the  knee  the  blow  is  fol- 
lowed normally  by  extension  of  the  leg  on  the  thigh,  a  move- 
ment always  more  or  less  extensive  and  sudden,  which 
always  follows  the  blow  after  an  inappreciable  interval. 
At  the  knee  the  jar  caused  in  the  limb  is  less 
apt  to  deceive  than  at  the  ankle.  The  presence  of  the 
reflex,  without  extension  or  movement  of  the  leg  is  often  re- 
vealed by  movement  of  fibres  of  the  quadriceps  muscle.  The 
exact  condition  of  the  deep  reflexes  can  never  be  known  un- 
less the  whole  naked  limb  is  exposed  to  view. 

Owing  to  the  normal  variations  of  the  knee-jerk  we  re- 
quire certain  means  of  estimating  whether  it  be  pathologi- 
cally reduced  or  increased.  Normally  the  knee-jerks  are 
practically  equal :  difference  is  always  pathologic ;  but  it 
is  necessary  to  determine  which  is  normal,  which  is  dimin- 
ished or  increased.  If  one  knee-jerk  be  lively,  without  the 
accompaniments  of  exaggeration  to  be  later  discussed,  and 
the  other  slight  or  less,  the  presumption  is  that  the  feebler 
is  abnormal.  When  both  knee-jerks  can  be  elicited  and  both 
are  lively,  it  is  probable  that  the  livelier  indicates  pathologic 
exaggeration. 

Jendrassik's  experiment  is  a  maneuver  that  causes  the 
knee-jerk  to  become  more  apparent.  It  is  performed  by 
causing  the  patient  to  make  some  muscular  effort  with  the 
hands  or  arms  (clinching  the  fists,  pulling  forcibly  with  the 
hands  clasped  together,  leaning  the  head  backward  against 
the  hands  tightly  clasped  behind  it,  usually  with  the  eyes 
closed),  while  the  examiner  strikes  the  tendon.  Often  by 
this  means  a  reflex  appears  that  could  not  be  elicited,  or  a 
feeble  one  becomes  livelier.     Feeble  and  equal  knee-jerks 


THE  DEEP  AND  SUPERFICIAL  REFLEXES.  83 

brought  out  by  this  procedure  are  not  necessarily  abnormal, 
though  they  may  be  so.  Probably,  contrary  to  the  opinion 
generally  entertained,  this  maneuver  acts  by  causing  com- 
plete relaxation  of  the  limbs. 

Permanent  contractures  of  muscles  may  prevent  the  deep 
reflexes  from  appearing  (mechanically  restrained)  as  in  some 
cases  of  chronic  organic  hemiplegia,  or  in  some  cases  of  hys- 
teric contracture.  In  such  cases,  with  no  deep  reflexes,  we 
should  not  conclude  that  the  reflexes  are  abolished,  but  rather 
say  that  they  cannot  be  elicited.  The  absence  of  the  knee- 
jerk  and  other  deep  reflexes  is  frequently  accompanied  by  de- 
crease of  muscle  tone,  as  a  result  of  which  the  joints  con- 
cerned can  be  over-flexed  or  over-extended.  This  is  also 
true  in  certain  cases  presenting  exaggerated  reflexes,  espe- 
cially before  there  has  been  any  development  of  contracture 
(early  stages  of  organic  hemiplegia). 

Exaggeration  of  the  knee-jerk  is  revealed  by  a  clonic 
movement  of  the  leg  when  the  tendon  is  tapped ;  by  patellar 
clonus  when  the  patella  is  depressed  forcibly  with  the  limb 
extended.  The  clonic  movements  of  an  exaggerated  knee- 
jerk  can  only  be  estimated  as  indicative  of  exaggeration 
through  experience  in  the  practical  examination  of  patients ; 
quality  and  distinctive  peculiarities  cannot  be  satisfactorily 
described.  To  an  experienced  observer  it  is  not  difficult  to 
distinguish  these  clonic  movements  from  the  lively  or  tremu- 
lous knee-jerk  of  normal  or  hysteric  persons. 

Lively  knee-jerks  can  be  called  exaggerated  (pathologic), 
in  the  absence  of  clonic  movements,  only  by  deduction  from 
the  simultaneous  presence  of  other  signs  of  damage  of 
the  central  motor  neurons  not  immediately  connected  with 
the  knee-jerk.  Exaggeration  of  the  knee-jerk  is  commonly 
associated  with  exaggeration  of  the  ankle- jerk,  both  due  to 


84  OUTLINES  OF   PSYCHIATRY. 

the  same  cause.  An  exaggerated  ankle-jerk  aside  from  the 
quick  movement  of  the  foot  when  the  tendo  Achillis  is  tap- 
ped, is  revealed  by  foot-clonus,  a  sign  that  has  never  yet 
been  demonstrated  except  in  organic  disease  of  the  nervous 
system,  the  characteristics  of  which  have  already  been  dis- 
cussed. 

,  Lively  deep-reflexes  on  one  side  associated  with  absence  of 
the  skin  reflexes  (abdominal,  cremasteric,  etc.)  on  the  same 
side,  is  a  state  that  justifies  a  presumption  of  the  existence  of 
organic  disease  of  the  nervous  system. 

Another  certain  sign  of  organic  nervous  disease  very  fre- 
quently associated  with  exaggerated  knee-jerk  and  foot-clo- 
nus, though  often  existing  alone,  is  the  so-called  toe-phenom- 
enon, or  sign  of  Babinski.  This  sign,  by  deduction,  may  re- 
veal the  pathologic  character  of  a  lively  knee-jerk.  Its  ab- 
sence constitutes  a  presumption  that  a  lively  knee-jerk,  with- 
out clonic  movements  and  without  foot-clonus,  is  physio- 
logic. 

Babinski's  sign  deserves  very  careful  study,  owing  to 
its  great  value  as  an  indication  of  organic  nervous  disease. 
It  is  necessary  to  know  how  to  examine  for  it,  how  to  avoid 
error  in  interpreting  it,  and  to  be  familiar  with  certain  varia- 
tions of  the  reflex  movements  of  the  toes  which  sometimes 
precede,  accompany,  or  replace  Babinski's  sign  and  have 
practically  the  same  significance. 

When  the  sole  of  the  foot  is  irritated  the  reflex  move- 
ment observed  is  called  the  plantar  reflex.  The  plantar  re- 
flex is  made  up  of  plantar  flexion  of  all  the  toes,  dorsal 
flexion  of  the  foot,  and  possibly  flexion  of  the  knee  and  con- 
traction of  the  tensor  vaginae  femoris  muscle.  Babinski's 
sign  is  a  variation  of  this  reflex,  and  is  essentially  extension 
of  the  great  toe,  though  all  the  toes  may  make  this  move- 


THE  DEEP  AND  SUPERFICIAL  REFLEXES.  85 

ment  simultaneously.  Babinski's  sign  occurs  in  infancy  and 
early  childhood  normally ;  it  also  occurs  in  strychnia  poison- 
ing ;  it  has  never  been  observed  in  hysteria  or  normal  persons 
(cases  cited  to  the  contrary  are  all  open  to  the  objection  of 
possible  error  of  observation).  The  most  frequent  source 
of  error  lies  in  the  fact  that  irritation  of  the  sole  causes  dorsal 
flexion  of  the  foot,  and  thus  all  the  toes  are  carried  upward, 
a  movement  which  may  readily  be  mistaken  for  extension  of 
the  toes,  especially  if  the  toes  flex  but  slightly,  or  not  at  all, 
as  may  be  the  case.  The  classic  sign  is  actual  extension  of 
the  great  toe,  which  is  best  observed  by  giving  attention  only 
to  the  great  toe  and  its  joints  (grasping  the  dorsum  of  the 
foot  with  one  hand  in  such  a  way  as  to  leave  the  toes  free 
and  conceal,  or  eliminate,  the  upward  movement  of  the  foot. 
The  irritation  of  the  sole  should  be  made  with  a  blunt  needle, 
but  in  some  cases  other  forms  of  irritation  suffice  (the 
finger,  a  pencil,  etc.).  The  reaction  occurs  also  very  mark- 
edly in  many  cases  when  cold  or  heat  is  applied  to  the  sole. 
Absolute  relaxation  of  the  limb  should  be  obtained.  The 
needle  should  be  applied  at  many  points  on  the  sole.  The 
examination  should  be  several  times  repeated.  If  the  toes 
flex  frankly  whenever  the  sole  is  pricked,  it  may  be  concluded 
that  the  reflex  is  normal;  if  they  are  immobile,  the  exami- 
nation should  be  frequently  repeated  before  reaching  a  con- 
clusion, for  such  a  phenomenon  may  precede  the  develop- 
ment of  Babinski's  sign. 

Babinski's  sign  may  not  vary  in  certain  cases  but  occur 
regularly  to  the  stimulus :  this  is  its  frank  manifestation.  It 
may  occur  alternately  with  flexion  of  the  toes,  or  only  from 
time  to  time  during  repetition  of  irritation  of  the  sole.  It 
always  has  the  same  significance;  for  it  never  occurs,  even 
occasionally,  in  health.    Another  variation  of  this  plantar  re- 


86  OUTLINES  OF   PSYCHIATRY. 

flex  recently  cited  by  Babinski  and  worthy  of  special  remark, 
is  abduction  of  all  the  toes  (they  spread  out  like  the  ribs  of 
a  fan).  This  movement  may  occur  with  or  without  exten- 
sion of  the  great  toe.  It  is  probably  a  variation  of  Babinski's 
sign.  It  has  been  observed  to  precede  the  development  of  a 
frank  sign  of  Babinski,  and  it  is  very  frequently  observed 
in  chronic  organic  hemiplegia.  If  it  has  not  the  diagnostic 
value  of  extension  of  the  great  toe,  it  has  a  very  high  pre- 
sumptive value  as  a  sign  of  organic  disease,  and  a  diagnosis 
of  functional  trouble  should  never  be  made  in  its  presence; 
in  any  case  it  should  be  regarded  as  rendering  a  diagnosis 
uncertain,  with  probability  of  organic  nervous  disease. 

I  have  recently  noted  another  variation  of  the  plantar  re- 
flex which  apparently  is  a  variation  of  Babinski's  sign :  with 
the  patient  lying  on  his  back  in  bed  with  the  legs  extended, 
when  the  sole  of  the  paralyzed  limb  was  irritated  occasional 
extension  of  the  toes  occurred,  but  invariably  there  was  a 
movement  of  the  foot  inward  and  slight  plantar  flexion  of 
the  foot,  evidently  due  to  contraction  of  the  peronei  muscles. 
This  movement  of  lateral  flexion  of  the  foot  is  in  contrast 
with  the  normal  dorsal  flexion  that  occurs  as  a  part  of  the 
normal  plantar  reflex.  I  have  observed  it  only  in  cases  in 
which  Babinski's  sign  ultimately  became  frank,  or  in  which 
Babinski's  sign  occurred  occasionally. 

In  conclusion  of  this  discussion  of  the  toe-phenomenon, 
it  should  be  added  that  the  extension  of  the  toe  may  take 
place  suddenly  or  in  a  slow  tonic  movement,  the  latter  being 
characteristic  of  its  frank  manifestation. 

There  are  many  other  more  or  less  valuable  signs  of  or- 
ganic disease  of  the  nervous  system.  To  discuss  them  in 
detail  would  take  us  too  far  from  our  primary  object  of 
study,  and  therefore  they  are  only  briefly  mentioned. 


THE  DEEP  AND  SUPERFICIAL  REFLEXES.  87 

Combined  flexion  of  the  trunk  and  thigh  (Bab- 
inski)  indicates  organic  nervous  disease.  Struempell's  sign 
(tonic  contraction  of  the  tabialis  anticus  when  the  knee 
and  hip  are  flexed)  is  seen  only  in  organic  paralysis. 
The  sign  of  the  platysma  (Babinski)  is  an  accompaniment  of 
organic  hemiplegia. 

Optic  nerve  inflammation  and  atrophy  have  great 
importance  as  related  to  organic  nervous  disease  and  in- 
sanity. 

Anesthesias  and  hyperesthesias  are  important. 
General  and  complete  anesthesia  is  never  a  sign  of  organic 
nervous  disease.  Disturbances  of  sensation  in  known  areas 
of  distribution  of  nerves  indicate  organic  disease  (peri- 
pheral). Anesthesia,  greatest  at  the  distal  parts  of  the  ex- 
tremities, decreasing  toward  the  trunk,  is  charatceristic  of 
organic  cerebral  disease.  Segmental  anesthesia  is  functional ; 
so  is  segmental  hyperesthesia;  but  that  related  to  nerve 
trunks  or  their  distribution  is  organic. 

Fibrillary  twitchings  are  almost  invariably  a  sign 
of  organic  disease,  and  of  great  significance  in  insanity  when 
they  are  seen  in  the  tongue,  lips,  and  face. 

Intention-tremor  usually  indicates  organic  disease 
(cerebellum). 

Aphasias,  and  drawling,  stumbling,  scanning 
speech  (asynergy),  are  organic  symptoms. 

Ataxia,  asynergy,  asterEognosis,  and  loss  of  muscle- 
sense  must  be  interpreted  with  relation  to  other  signs  of 
organic  cerebral  disease. 

Apoplectiform  and  epileptiform  attacks  in  the  be- 
ginning or  during  the  course  of  insanity  are  signs  of  organic 
cerebral  disease.  They  may  be  the  first  symptoms.  If  they 
occur  in  a  person  not  subject  to  epilepsy  they  practically  in- 


88  OUTLINES   OF   PSYCHIATRY. 

dicate  the  organic  nature  of  subsequent  mental  disturbance. 
Late  epilepsy  is  only  to  be  distinguished  by  the  course,  unless 
other  signs  of  organic  disease  are  present.  Uremia  and  in- 
toxication must  be  considered  in  diagnosis  in  connection 
with  such  attacks. 

A  new  and  most  important  means  of  diagnosis,  is  exami- 
nation of  the  cerebro-spinal  fluid  obtained  by  lumbar  punc- 
ture. Organic  diseases  of  the  meninges  (tabes,  paretic  de- 
mentia, meningitis)  cause  cytologic  and  chemical  alterations 
of  the  fluid  which  are  never  found  in  functional  nervous  dis- 
turbances. 


LESSON  XII. 
The  Etiology  of  Insanity. 

The  statistics  of  insanity  gathered  in  the  numerous  in- 
stitutions of  the  world  are  the  basis  of  study  of  causes. 
Statistics  are,  in  the  nature  of  things,  imperfect,  for  only  a 
certain  proportion  of  the  insane  is  found  in  hospitals  for  the 
insane.  Late  statistics  prove  that  for  every  thousand  of  the 
population  there  are  from  three  to  six  insane  persons.  The 
reported  proportion  varies  in  different  countries,  but  is 
always  below  the  actual  proportion.  The  number  of  insane 
persons  is  actually  and  ostensibly  gradually  increasing,  be- 
cause care  of  the  insane  prolongs  their  lives,  increasing  thus 
the  insane  population;  and  of  late  years  great  care  in  diag- 
nosis discovers  insane  persons  that  were  formerly  disre- 
garded. Insanity  is  probably  increasing  actually  because 
certain  causes  are  more  active.  In  the  first  place,  the  insane 
are  better  treated  and  discharges  of  recovered  or  improved 
patients  increase;  patients  that  would  have  been  doomed  to 
dementia  and  death  without  possibility  of  progeny  are  now 
in  large  and  increasing  number  given  opportunity  to  repro- 
duce their  kind  in  the  fullest  sense.  This  partly  explains  an 
evident  increasing  predominance  of  heredity  in  insanity. 

The  consumption  of  alcohol  and  other  stimulants  in- 
creases more  rapidly  than  population.  This  is  an  important 
cause  of  insanity,  either  directly,  or  in  descendants  as  a 


90  OUTLINES   OF   PSYCHIATRY. 

result  of  inheritance  of  nervous  defects  engendered  in  pro- 
genitors by  excessive  use  of  such  poisons. 

Syphius,  always  a  menace  to  the  nervous  system  of  one 
that  has  contracted  it,  grows  more  and  more  widespread, 
because  of  the  constantly  increasing  facility  of  intercom- 
munication between  country  and  towns  and  cities.  It  will  be 
remembered  that  in  the  fifteenth  century  syphilis  first  be- 
came generally  known — a  period  when  international  re- 
lations began  to  develop  rapidly.  Those  that  traveled  fur- 
thest (Columbus)  were  accused  of  bringing  it  back.  The 
Spaniards  blamed  the  Indians;  the  French  blamed  the  Ital- 
ians. It  was  merely  the  facility  of  promiscuity  of  nations 
that  brought  an  ancient  malady  into  prominence  because  of 
increase  of  commercial  or  belligerent  intercourse. 

Syphilis  exerts  an  increasingly  bad  influence  on  the  nerv- 
ous system  for  other  reasons  than  the  disease  itself.  These 
are  found  in  the  strain  of  modern  life  and  civilization  on  the 
nervous  -system,  leading  to  over-excitement  and  exhaustion, 
which,  though  in  themselves  capable  of  causing  insanity, 
seem  to  determine  a  selective  action  of  syphilis  on  the 
nervous  system.  Locomotor  ataxia  and  paretic  dementia  are 
caused  by  syphilis,  but  they  are  widespread  only  in  highly 
civilized  countries.  The  Arabs  of  Northern  Africa  are 
syphilitic  but  very  rarely  tabetic  or  paretic. 

There  is  an  excess  of  insane  males  over  insane  females, 
probably  as  a  result  of  the  greater  strain  of  work  and  the 
excesses  to  which  men  are  exposed. 

Racks  present  variations  of  mental  morbidity,  probably 
owing  to  certain  special  influences  affecting  them,  as  well  as 
to  inherent  conditions.  The  Jewish  race  is  notoriously  neu- 
rotic, possibly  as  a  result  of  inbreeding;  for  as  a  race  the 


THE  ETIOLOGY  OF  INSANITY.  91 

Jews  are  temperate  and  on  the  whole  less  exposed  to  ven- 
ereal disease  than  others. 

Occupation  as  a  possible  cause  of  insanity  is  hardly 
worth  discussing,  aside  from  the  fact  that  certain  forms  of 
work  expose  to  influences  that  act  as  exciting  causes  (lead, 
noxious  gases). 

The  predisposing  causes  of  insanity  are  hereditary  or 
acquired.  A  certain  person  having  much  insanity  in  an- 
cestry is  said  to  be  predisposed  by  heredity  to  insanity ;  an- 
other that  presents  certain  neurotic  or  neuropathic  symptoms 
is  predisposed  to  insanity.  If  there  be  no  insane  or  neurotic 
ancestry  the  predisposition  may  be  congenital  (symptoms 
shown  early),  or  acquired  (injurious  influences  during  de- 
velopment or  later). 

If  insanity  develop  on  the  basis  of  predisposition,  pre- 
disposition is  the  fundamental  cause;  exciting  causes  are 
subsidiary.  Thus  when  it  is  said  that  a  person  is  predis- 
posed to  insanity,  either  he  has  an  insane  ancestry,  of  he  pre- 
sents certain  nervous  and  mental  symptoms  that  are  known 
to  precede  often  the  development  of  insanity. 

Hereditary  predisposition  to  insanity  is  proved  by 
the  history;  congenital  and  acquired  predisposition  are  re- 
vealed by  symptoms  present  in  the  individual.  Am  insane 
ancestry  casts  suspicion  on  descendants,  and  this  suspicion  is 
called  hereditary  predisposition.  When  certain  neuropathic 
symptoms  are  present  in  an  individual  they  justify  a  diag- 
nosis of  a  predisposition  to  insanity.  Their  relation  to  her- 
edity (insanity,  neuroses,  etc.,  in  progenitors)  can  only  be 
established  by  the  history  of  the  family. 

The  signs  of  a  neuropsychopathic  predisposition  may  be 
indicated  rather  than  defined :  infantile  convulsions ;  night- 
terrors  ;  incontinence  of  urine  in  childhood ;  striking  eccen- 


92  OUTLINES   OF   PSYCHIATRY. 

tricity  of  character  not  due  to  education ;  lack  of  develop- 
ment of  normal  moral  feeling  under  proper  education; 
marked  intellectual  dullness ;  delirium  in  slight  fever ;  marked 
intolerance  of  alcohol  in  youth ;  useless  lying ;  want  of  pa- 
rental or  filial  affection ;  cruelty ;  special  endowment  in  a 
limited  direction  with  low  powers  in  other  directions ;  great 
mental  and  emotional  impressionability;  circulatory  and 
vasomotor  instability;  epilepsy;  hysteria;  hypochondria; 
general  nervous  weakness  devoid  of  sufficient  cause;  illogical 
suspicions ;  illogical  selfish  argumentativeness  and  unreason- 
able obstinacy — these  are  some  of  the  many  ways  in  which 
predisposition  to  insanity  may  be  indicated,  but  which  may 
or  may  not  be  followed  by  insanity. 

Insanity  once  developed,  a  history  of  such  symptoms  pre- 
ceding it  may  help  to  determine  the  nature  of  the  mental  dis- 
ease. 

The  factors  that  make  up  predisposition  are  the  basis 
of  psychic  degeneracy.  Aside  from  primary  organic  and  in- 
fectious insanities,  almost  all  psychoses  are  of  a  degenerate 
nature.  The  closer  the  so-called  simple  and  accidental  insan- 
ities are  studied  the  more  apparent  it  becomes  that  they  are 
only  one  link  in  the  chain  of  psychic  degeneracy.  A  simple 
melancholia  is  as  sure  a  sign  of  weakness  of  nervous  con- 
stitution as  is  a  perfectly  developed  system  of  delusions  of 
persecution,  only  they  indicate  different  degrees  of  psycho- 
pathic "degeneracy"  or  weakness:  melancholia  may  pass; 
the  systematized  delusions  remain. 

Insanity,  with  a  few  organic  exceptions,  is  a  sign  of  in- 
feriority of  nervous  and  cerebral  constitution. 

Insanity  is  not  hereditary  in  the  strict  sense  of  the  word ; 
feelings  and  thoughts,  normal  or  abnormal,  are  not  inher- 
ited.    However,  it  is  convenient  to  speak  of  hereditary  in- 


THE  ETIOLOGY  OF  INSANITY.  93 

sanity.  The  inheritance  is  physical, — a  physical  constitu- 
tion, which,  being  like  that  which  engendered  it,  is  apt  to  dis- 
play similar  anomalies  of  function. 

The  history  of  families  presenting  insanity  permits  us  to 
distinguish  three  kinds  of  insane  inheritance:  (1)  direct 
(mother  or  father  or  both  insane)  ;  (2)  indirect  or  collateral 
(insane  uncles,  aunts,  or  cousins;)  (3)  atavistic  (insanity  in 
grandparents,  great-grandparents  or  in  other  ancestral  lines). 

When  the  insanity  is  of  the  same  kind  in  various  mem- 
bers of  a  family  the  heredity  is  called  like;  when  varied,  un- 
like or  polymorphus.  Often  the  neuroses  beget  insanity 
and  z'icc  versa;  this  is  called  transformed  heredity. 

A  congenital  and  hereditary  physical  condition  of  weak- 
ness that  predisposes  to  insanity  is  frequently  traceable  to 
alcoholism,  morphinism,  syphilis,  general  enfeeblement,  etc., 
in  the  parents. 

It  is  probable  that  during  intra-uterine  life  injurious  in- 
fluences affecting  the  mother  may  affect  the  child  and  thus 
cause  imperfect  development. 

Accidental  predisposition  results  from  all  influences 
that  tend  to  weaken  the  organism  or  to  retard  or  arrest  its 
development.  As  a  rule,  accidental  or  acquired  predisposi- 
tion results  from  influences  operative  during  the  earlier  years 
of  life.  Of  these  the  most  important  are  severe  diseases, 
anemia,  sexual  excesses,  drunkenness,  and  head  injuries. 

The  preponderating  importance  of  an  inherited  or  ac- 
quired predisposition  to  insanity  is  most  strikingly  shown  in 
the  influence  of  certain  physiologic  phases  of  life  to  favor  the 
outbreak  of  mental  disease. 

Childhood  may  be  said  to  exert  no  influence;  the  in- 
sanity of  childhood  is  comparatively  rare  and  almost  always 


94  OUTLINES  OF   PSYCHIATRY. 

the  direct  expression  of  a  defective  nervous  organization 
evidenced  by  other  signs. 

Puberty  is  a  very  dangerous  period  for  the  defective 
nervous  constitution.  A  large  percentage  of  cases  of  insan- 
ity begin  during  this  phase  of  development,  and  in  the  ab- 
sence of  any  direct  or  sufficient  exciting  cause. 

The  climacteric  in  women,  the  period  of  sexual  in- 
volution, also  favors  very  markedly  the  development  of  in- 
sanity. In  a  large  proportion  of  insane  females,  the  begin- 
ning of  the  disease  coincides  with  this  biologic  phase.  For 
women  this  phase,  in  general,  extends  from  the  fortieth  to 
the  fiftieth  year. 

There  is  said  to  be  a  male  climacteric  from  the  fifty-fifth 
to  the  sixtieth  year ;  but  male  climacteric  insanity,  so-called, 
is  senile  insanity. 

Menstruation  has  a  profound  effect  upon  the  mental 
state  of  many  women,  and  in  some  cases  it  is  attended  by 
formal  insanity,  which  may  be  temporary  or  periodic;  but  it 
may  finally  be  continuous.  Menstruation  also  often  aggra- 
vates temporarily  chronic  insane  states. 

Pregnancy,  in  the  predisposed,  is  a  frequent  cause  of 
alienation.  The  mental  disturbance  may  begin  and  cease 
with  pregnancy,  or  continue. 

The  puerperal  state  is  a  fertile  cause  of  mental  dis- 
ease, either  temporary  or  chronic  in  nature.  In  such  cases 
it  is  necessary  to  distinguish  between  the  functional  psy- 
choses developed  on  the  basis  of  a  marked  predisposition 
and  insanity  due  to  an  infection,  uremia,  embolism,  menin- 
gitis, etc. 

The  period  oe  lactation  also  favors  the  occurrence 
of  insanity  in  the  predisposed,  probably  through  the  anemia 
and  exhaustion  it  may  cause. 


THE  ETIOLOGY  OF  INSANITY.  95 

The  exciting  or  direct  causes  oe  insanity  are 
such  as  to  act  immediately  to  bring  the  outbreak.  They  are 
mental  or  physical  or  both. 

The  mental  causes  may  act  suddenly  or  gradually.  Men- 
tal shock,  sudden  sorrow  or  joy,  fright,  the  psychic  shock 
attending  physical  injuries,  are  examples  of  mental  causes 
that  may  induce  insanity  immediately  or  after  a  compara- 
tively short  interval.  Sorrow,  care,  disappointment  in  life, 
in  love,  etc.,  are  mental  causes  that  act  more  or  less  slowly 
to  induce  mental  disease. 

Psychic  contagion  is  sometimes  a  cause  of  insanity  in 
the  weak-minded.  It  usually  occurs  in  families :  one  insane 
person  in  the  family  causes  others  to  accept  delusions,  hallu- 
cinations, etc. 

The  physical  and  somatic  exciting  causes  are  numer- 
ous. Head  injuries  may  cause  insanity  without  the  interven- 
tion of  mental  shock  (organic  cerebral  injury). 

The  neuroses,  epilepsy,  hysteria,  and  chorea,  are  regarded 
as  causes  of  insanity  because  subjects  of  them  often  develop 
mental  disease.  Epilepsy  often  becomes  associated  with  in- 
sanity. Hvsteria  is  a  mental  anomalv,  and  insanitv  follow- 
ing  it  is  the  development  of  the  primary  psychoneurosis. 
Chorea  is  practically  always  accompanied  by  mental  disturb- 
ance, and  choreic  insanity  is  only  a  more  marked  develop- 
ment of  a  fundamental  element  of  the  symptom-complex. 

More  direct  physical  causes  are  arteriosclerosis,  cerebral 
hemorrhage,  cerebral  softening,  cerebral  tumors,  acute  and 
chronic  disease  of  the  meninges,  etc. 

Disease  of  the  internal  organs  sometimes  causes  insan- 
ity— pulmonary  tuberculosis;  disease  of  the  heart;  gastro- 
intestinal diseases ;  auto-intoxication ;  disease  of  the  thyroid 


96  OUTLINES  OF   PSYCHIATRY. 

gland ;  disease  of  the  sexual  organs ;  disease  of  the  kidneys, 
etc. 

Infectious  diseases  are  frequent  causes  of  insanity. 
Among  the  more  important  are  syphilis,  typhoid,  and  la 
grippe. 

Intoxication  holds  a  very  important  place  in  the  etiol- 
ogy of  mental  disease:  alcohol,  morphine,  lead,  mercury, 
etc. 

It  is  a  matter  of  careful  judgment  in  a  case  of  insanity 
to  correctly  estimate  the  relative  importance  of  predisposing 
and  exciting  causes,  and  of  value  in  prognosis. 


LESSON  XIII. 
The  Course  and  Termination  of  Insanity. 

Rarely  the  outbreak  of  insanity  is  sudden  after  trauma  or 
mental  shock,  or  after  an  epileptic  attack ;  usually  the  insane 
condition  develops  gradually  through  a  prodromal  period 
presenting  general  bodily  disturbances,  sleeplessness,  irrita- 
bility, moodiness,  depression  or  excitement. 

The  course  of  insanity,  its  duration  and  variations, 
presents  several  types. 

Transitory  insanity  is  that  which  lasts  from  a  few- 
minutes  to  several  hours ;  it  is  usually  of  very  sudden  onset 
with  sudden  termination  in  lucidity.  Such  attacks  of  transi- 
tory insanity  should  be  examined  with  a  view  to  determine 
their  possible  relation  to  epilepsy  (equivalent)  and  hysteria, 
or  to  some  form  of  intoxication  (alcohol,  belladonna,  nox- 
ious gases)  ;  delirious  attacks  that  have  no  discoverable 
physical  cause  must  be  attributed  to  inherent  brain  defect 
or  to  some  insidious  cerebral  disease  (dementia  paralytica). 

Acute  insanity  is  conventionally  understood  to  cover 
cases  that  gradually  develop  and  last  from  six  or  eight 
months  to  a  year,  with  moderate  intensity  of  symptoms. 

The  course  of  an  acute  or  sub-acute  insanity  may  be  in- 
terrupted by  periods  of  remission  of  the  acute  symptoms; 
and  sub-acute  cases  may  present  periods  of  aggravation  with 
very  acute  and  active  symptoms. 

97 


98  OUTLINES  OF    PSYCHIATRY. 

Chronic  insanity  is  a  term  properly  applied  to  any 
case  of  insanity  that  lasts  more  than  a  year.  Chronic  in- 
sanity may  be  the  termination  of  acute  or  sub-acute  insan- 
ity, or  it  may  be  that  the  type  from  the  beginning  is  that  of 
chronic  insanity.  In  the  latter  case  it  is  the  character  of 
the  symptoms  that  justifies  the  use  of  the  term  chronic 
(paranoia).  Chronic  insanity  may  present  acute  exacerba- 
tions of  longer  or  shorter  duration,  characterized  by  symp- 
toms of  the  acute  forms  of  mental  disease. 

Periodic  insanity  means  mental  disease  that  occurs 
and  runs  its  course  with  a  certain  periodicity.  Usually  the 
attack  is  acute  and  of  comparatively  short  duration.  This 
is  repeated  with  regularity  or  at  irregular  intervals.  When 
the  attacks  are  widely  separated  we  call  the  case  one  of  re- 
current insanity,  in  which  the  types  in  different  attacks  may 
be  the  same  or  different. 

Circular  insanity  is  a  type  of  periodic  insanity  char- 
acterized by  a  certain  procession  of  mental  symptoms;  for 
example,  a  period  of  melancholia  is  followed  by  a  period  of 
mania,  and  this  by  a  period  of  lucidity.  The  order  and  the 
length  of  these  periods  vary  and  that  of  lucidity  may  be 
practically  wanting.  It  may  be  noted  that  the  so-called  func- 
tional psychoses  often  present  a  certain  procession  of  symp- 
toms that  suggests  the  phases  of  circular  insanity :  mania  is 
usually  preceded  by  a  period  of  depression  or  melancholia, 
and  it  may  be  followed  by  a  similar  period  of  depression ;  it 
may  be  difficult  or  impossible  to  distingush  a  period  of  ex- 
citement in  the  course  of  melancholia  from  that  characteris- 
tic of  mania.  These  facts  only  serve  to  demonstrate  the  fun- 
damental relation  of  all  psychoses  in  a  psychologic  sense. 

The  termination  of  acute  insanities  may  be  recovery 
(cure)  ;  recovery  with  defect  (slight  dementia)  ;  secondary 


THE  COURSE  AND  TERMINATION  OF  INSANITY.  99 

delusional  (chronic)  insanity;  secondary  dementia  with  ab- 
sence of  all  active  mental  symptoms.  Secondary  agitated 
dementia  is  dementia  with  motor  excitement;  apathetic  de- 
mentia without  motor  or  emotional  excitement. 

There  are  various  degrees  of  secondary  dementia  extend- 
ing from  that  difficult  of  recognition  to  that  representing 
absolute  absence  of  mind.  When  the  active  symptoms  of  in- 
sanity have  subsided,  if  no  signs  of  loss  of  mental  vigor 
remain,  the  patient  is  regarded  as  cured ;  if  dementia  be  no- 
ticeable though  the  patient  is  able  to  maintain  a  place  in  so- 
ciety, he  is  called  a  case  of  recovery  with  mental  defect 
(improved). 

The  vast  majority  of  patients  discharged  from  institu- 
tions for  the  insane  are  secondary  dements.  "Recoveries" 
are  practically  always  doubtful ;  they  must  stand  the  test  of 
time.  The  so-called  "recoveries"  in  statistics  of  hospitals  for 
the  insane  bear  a  searching  examination  for  dementia  and 
last  indefinitely  only  in  a  small  proportion  of  cases.  In  gen- 
eral, restoration  of  mental  integrity  after  an  attack  of  insanity 
is  rare.  This  statement  is  made  with  full  knowledge  of  the 
improvements  that  modern  treatment  of  the  insane  has 
brought  about.  Insanity  remains  what  it  has  always  been, — 
a  stigma  of  inferiority.  With  few  exceptions,  insanity  is  a 
manifestation  of  an  imperfect  organization,  and  therefore  will 
be  regarded  as  it  has  always  been  regarded.  An  effort  to  have 
insanity  looked  upon  as  a  disease  like  the  measles  or  whoop- 
ing cough,  will  never  make  headway  except  among  the  in- 
sane and  weakminded  philanthropists.  Insanity  is  a  sign 
which  justifies  a  presumption  of  defective  organization ;  and 
a  person  that  has  manifested  it  will  always  be  regarded  as 
different  from  those  that  have  not.  Science  now  teaches  the 
truth  of  this;  but  it  was  taught  the  world  by  experience  long 


100  OUTLINES  OF   PSYCHIATRY. 

before  science  occupied  itself  with  the  nature  of  insanity.  But 
insanity  in  itself  is  no  more  a  cause  for  shame  than  any  other 
accident  of  life;  it  should  excite  pity  and  care,  and  every 
effort  should  be  made  to  restore  the  insane  and  to  keep  them 
near  mental  health.  A  natural  deduction  from  these  remarks 
is  that  the  true  cure  of  insanity  lies  in  prevention ;  but  here 
we  encounter  an  ideal  that  cannot  be  realized. 

Death  may  be  a  termination  of  insanity.  It  is  the  nor- 
mal result  of  organic  insanities;  it  may  occur  from  exhaus- 
tion due  to  insanity ;  it  may  result  from  accidents  favored  by 
the  insane  condition ;  it  may  be  the  consequence  of  the  insane 
ideas  (suicide)  ;  it  may  result  from  intercurrent  infections 
favored  by  the  insane  state;  an  insane  person  may  die  from 
causes  having  no  relation  to  insanity,  like  any  other  person. 

The  pathologic  anatomy  oe  insanity,  properly 
speaking,  does  not  exist.  Many  cases  of  insanity  show  no 
post-mortem  changes  other  than  those  due  to  the  manner  of 
death — cerebral  anemia,  hyperemia,  etc.  Gross  anatomical 
changes  are  common — alterations  of  the  meninges,  adhe- 
sions, etc.,  but  these  are  neither  specific  nor  characteristic. 
Minute  changes  in  the  nerve-cells  are  found,  but  they  also  are 
not  distinctive. 

Gross  and  minute  anatomical  lesions  of  the  brain  are 
found  in  idiocy,  imbecility,  and  the  organic  insanities.  There 
are  findings  more  or  less  characteristic  of  paretic  dementia, 
and  an  atrophy  and  loss  of  brain  weight  with  meningeal 
changes  characteristic  to  a  certain  extent  of  secondary  de- 
mentia. 

The  diagnosis  oe  insanity  presents  two  problems : 
diagnosis  of  insanity  per  se;  diagnosis  of  the  form  or  nature 
of  the  disease. 


THE  COURSE  AND  TERMINATION  OF  INSANITY.  101 

It  may  be  easy  or  very  difficult  to  diagnosticate  insanity ; 
it  may  be  easy  or  very  difficult  to  classify  the  case.  The  ease 
with  which  insanity  is  recognized  in  many  cases  by  the  public 
is  notorious;  the  frequent  disagreement  of  alienists  suf- 
fices to  emphasize  the  difficulty  encountered  in  some  cases. 
In  certain  cases  it  may  be  necessary  to  observe  an  individual 
for  an  extended  period  under  favorable  circumstances,  be- 
fore a  conclusion  can  be  reached. 

It  is  usually  possible  to  make  a  positive  diagnosis  in  the 
organic  insanities ;  here  the  physical  symptoms  are  of  great 
additional  assistance. 

In  functional  psychoses  the  difficulties  arise  from  the 
fact  that  all  somatic  signs  may  be  wanting,  and  we  are 
forced  to  base  our  judgment  on  mental  symptoms  alone.  The 
mental  symptoms  that  constitute  insanity  may  be  assumed 
or  dissimulated;  a  sane  person  may  imitate  mental  disease; 
an  insane  person  may  imitate  sanity.  Simulation  of  insanity 
is  common  in  the  effort  to  escape  the  consequences  of  crime ; 
dissimulation  of  insanity  is  often  practiced  to  escape  the 
consequences  of  insanity — confinement  and  opposition  to  the 
impulsion  of  delusional  ideas. 

Other  difficult  cases  are  those  that  concern  the  disposal 
of  property,  in  which  the  existence  of  mental  soundness  de- 
termines the  legality  of  donations,  wills,  etc. 

The  diagnosis  OF  recovery  with  reference  to  decision 
of  the  question  of  restoring  a  patient's  personal  liberty  is 
always  a  matter  requiring  great  care  and  judgment.  The 
gravest  error  in  this  sense  is  to  mistake  dissimulation  for 
recovery.  Likewise,  remissions  may  appear  in  the  guise  of 
recovery.  It  is  the  uncertainty  inherent  in  the  nature  of  in- 
sanity that  makes  prolonged  detention  of  the  patient  neces- 


102  OUTLINES  OF   PSYCHIATRY. 

sary  after  all  acute  symptoms  of  insanity  have  disappeared. 
The  fact  that  the  diagnosis  of  insanity  is  often  difficult  is 
no  exception  to  the  general  rule  in  pathology,  and  the  prob- 
lems presented  in  mental  disease  are  no  more  enigmatical 
than  those  that  confront  us  in  internal  medicine. 


LESSON  XIV. 


Classification  of  Insanity. 

For  practical  clinical  purposes  we  may  distinguish  two 
classes  of  cases  of  insanity:  (1)  organic,  (2)  functional. 
Insanity  is  always  a  symptom,  and  therefore  always  indi- 
cates some  form  of  physical  disorder  of  the  brain. 

When  signs  and  symptoms  of  organic  disease  of  the 
nervous  system  (brain)  and  the  mental  signs  and  symp- 
toms that  constitute  insanity  co-exist,  or  when  the  mental 
symptoms  can  be  referred  to  some  material  cause  (poisons), 
the  case  is  one  of  organic  mental  disease. 

When  changes  in  the  cortex  reveal  themselves  only  in 
mental  disorder,  and  when  the  mental  symptoms  are  not  di- 
rectly referable  to  destructive  alterations  of  the  cortex,  or 
to  some  material  cause  known  to  affect  the  cortex  especially 
in  its  mental  functions,  we  may  for  practical  reasons  speak 
of  the  insanity  as  simple  or  functional. 

Organic  insanity  is  such  only  because  of  the  co-existence 
of  signs  and  symptoms  or  organic  disease  of  the  nervous 
system  and  symptoms  of  mental  disease;  otherwise,  in  the 
absence  of  mental  symptom  the  case  is  one  of  organic  nerv- 
ous disease  merely.  Thus  organic  and  functional  insani- 
ties are  revealed  by  the  same  kinds  of  symptoms  as  far  as 
the  insanity  itself  is  concerned. 

Within   the  domain   of  purely    mental    manifestations 

103 


104 


OUTLINES  OF    PSYCHIATRY. 


there  are  symptoms  as  surely  indicative  of  organic  disease 
of  the  brain  as  are  certain  physical  signs  and  symptoms. 
Such  mental  symptoms  are  always  those  of  loss  of  mind 
(dementia)  or  of  want  of  development  of  mind  (idiocy). 

An  insanity  primarily  functional,  may  pass  into  de- 
mentia (become  organic.) 

The  symptoms  of  insanity,  since  they  are  always  men- 
tal, are  made  up  of  anomalies  of  thinking  and  feeling  and 
acting.  The  symptomatic  type  of  insanity  is  most  aptly 
named  from  the  predominating  mental  symptoms.  Thus 
melancholia  and  mania  are  so  named  because  anomalies 
of  the  feelings  dominate  the  clinical  picture;  delusional  in- 
sanity indicates  the  predominance  of  ideational  anomalies; 
dementia  shows  that  loss  or  inactivity  of  mind  is  the  most 
prominent  symptom. 

Since  insanity  is  essentially  a  disturbance  of  mental 
functions  the  first  group  of  insanities  should  be  made  with 
reference  to  the  predominance  of  certain  mental  symptoms 
that  have  been  empirically  established  as  representative 
types  of  the  psychoses. 


A.   Emotional. 


a.  Depression,      i.   Melancholia. 

b.  Exaltation,       2.   Mania. 

a.  Distortion,        3.  Delusional. 


B.    Intellectual. < 


4.   Hallucinatory  (confusional) 
j  b.  Exhaustion,^  delirium. 

[  ^5.   Dementia  (stupor). 

All  insanities  known  may  be  symptomatically  classified 
in  these  five  groups.  It  is  by  the  presence  of  these  symptoms 
that  the  existence  of  insanity  is  determined.  But  study  of 
cases  of  insanity  at  once  makes  it  apparent  that  considera- 


CLASSIFICATION   OF    INSANITY.  105 

tion  of  the  mental  picture  alone  is  inadequate;  for,  aside 
from  the  possibility  of  being  but  an  aspect  of  organic  in- 
sanity, these  mental  symptoms  may  present  numerous  pecul- 
iarities besides  their  immediate  psychic  qualities.  A  melan- 
cholia may  be  an  episode  in  the  course  of  a  senile  con- 
dition ;  it  may  be  the  result  of  intoxication  (alcohol)  ;  it  may 
be  a  phase  of  a  primary  delusional  insanity  (paranoia). 
Any  of  the  symptomatic  forms  of  insanity  may  present  pe- 
culiarities or  be  associated  with  other  signs  and  symptoms 
which  make  it  necessary  to  go  further,  and  classify  the 
individual  as  well  as  his  symptoms. 

When  insanity  of  any  functional  type  presents  certain 
peculiarities  of  symptomatic  detail,  in  variability,  origin 
and  course,  the  disease-picture  has  a  profounder  meaning — 
it  is  a  symptom  of  psychic  degeneracy. 

Aside  from  certain  peculiarities  of  mental  symptoms, 
often  it  is  the  history  or  the  course  of  the  mental  anomaly 
that  makes  a  diagnosis  of  its  degenerate  significance  possi- 
ble. All  forms  of  functional  insanity  are  more  or  less  de- 
generate, but  certain  forms  are  strikingly  degenerate,  either 
owing  to  their  symptomatic  peculiarities  or  their  course. 

The  frankly  degenerate  functional  insanities  differ  from 
the  simple  insanities  in  cause,  evolution,  course,  and  termina- 
tion. However,  as  will  be  seen  later  in  the  descriptions  of 
the  types  of  insanity,  in  certain  cases  it  is  impossible  to 
draw  a  distinct  line  between  simple  insanity  and  degenerate 
insanity. 

Some  of  the  peculiarities  that  distinguish  the  forms  of 
frankly  degenerate  insanity  are : 

1.  Simple  recurrence. 

2.  Periodicity. 

3.  Variation  of  symptomatic  type  (circular). 


106 


OUTLINES  OF    PSYCHIATRY. 


4.     Remission   with    relapse   and   continuance   of   the 


original  course. 

5.  Long  period  of  development  (long  prodromes). 

6.  Initial  and  primary  intellectual  symptoms   (delus- 
ions). 

7.  Logical   systematization   of  delusions    (alterations 
of  the  personality) . 

8.  Absence  of  adequate  cause. 

9.  Previous  rudimentary  symptoms  of  insanity  (pho- 
bias, imperative  ideas). 

10.  Association  with  marked  signs  of  physical  degen- 
eracy. 

11.  Development  out  of  a  degenerate  neurosis. 

The    degenerate    insanities    may    be    conveniently 
grouped  as  follows : 


ra. 

Recurrent  insanity. 

A. 

Periodic.                   < 

b. 

[c. 

Periodic  insanity. 

Circular  insanity. 

ra. 

Rudimentary  paranoia  (phobias) 

B. 

Paranoiac.                < 

b. 
c. 

Reasoning  insanity. 
Early  paranoia. 

Ld. 

Late  paranoia. 

"a. 

Epileptic. 

C. 

Neurotic.                 i 

b. 
c. 

Choreic. 
Hysteric. 

d. 

Hyponchondriac. 

CLASSIFICATION   OF   INSANITY. 


107 


This  enumeration  is  not  exhaustive;  new  detailed  types 
of  mental  degeneracy  are  constantly  being  added. 

Any  of  the  functional  insanities,  simple  or  frankly  de- 
generate, may  through  ohronicity,  become  organic. 

The  organic  insanities,  as  here  understood,  include 
all  cases  of  mental  disease  that  can  be  referred  to  a  physical 
basis  or  a  material  cause. 

'"i.  Atheroma. 

2.  Hemorrhage. 

3.  Softening. 

A.   Insanity  due  to  gross  brain  disease.^  4.  Inflammation. 

5.  Tumors. 

6.  Brain  atrophy. 

7.  Trauma. 
Syphilis. 
All  other  forms  of  infections. 

Alcohol,  lead,  etc. 
fi.  Uremia. 

D.  Insanity  due  to  auto-intoxication.    ^  2.  Diabetes. 

I 

^3.  Thyroid  disease. 

The  organic  insanities  are  either  the  result  of  physical 
agencies  affecting  the  brain  in  its  functions,  or  of  organic 
changes  in  the  elements  of  the  brain  itself. 

Of  all  forms  of  insanity,  those  included  under  the  term 
"simple"   are  the  rarest;  next  in  order  of  frequency  are 


B.  Insanity  due  to  infections. 

C.  Insanity  due  to  intoxication 


108  OUTLINES  OF   PSYCHIATRY. 

those  primarily  organic  in  nature;  and  most  frequent  of  all 
are  the  degenerate  insanities. 

The  cases  of  secondary  dementia  that  result  from  pri- 
mary functional  states  all  practically  belong  to  the  organic 
group. 

According  to  this  grouping  of  cases  the  diagnostician  has 
three  problems  to  solve: 

1st.  Is  the  patient  insane?  A  question  to  be  answered 
solely  by  examination  of  mental  symptoms. 

2d.  Is  the  insanity  functional  or  organic?  A  question 
to  be  answered  by  exclusion  of  signs  and  symptoms  of  or- 
ganic causes  of  functional  disturbance  (intoxication,  infec- 
tion, gross  and  minute  brain  disease). 

3d.  In  the  absence  of  signs  of  organic  disease,  is  the 
insanity  simple  or  degenerate?  This  is  the  most  difficult 
question  to  answer,  because  it  is  very  difficult  to  limit 
exactly  "degeneracy"  by  definition,  and  because  the  func- 
tional disturbance,  though  apparently  simple,  may  be  but 
the  initial  stage  of  psychic  degeneration.  For  this  reason 
it  may  be  impossible  to  make  a  decisive  diagnosis  without 
prolonged  observation. 

In  the  description  of  the  types  of  insanity  to  follow  the 
points  that  enable  an  immediate  solution  of  the  question  of 
marked  degeneracy  will  be  made  plain. 

Of  the  apparently  simple  functional  insanities  certain 
ones  are  often  signs  of  degeneracy,  especially  mania  and 
acute  primary  dementia.  These  clinical  pictures,  when  pro- 
duced by  material  causes — alcohol,  physical  exhaustion — 
may  be  without  degenerate  meaning. 

It  is  also  to  be  remarked  that  mania  is  very  disastrous 
in  its  ultimate  effect  on  the  mind;  it  is  only  rarely  that 
active  maniacal  symptoms  subside  without  leaving  a  perm- 


CLASSIFICATION  OF  INSANI1Y.  109 

anent  mental  defect — dementia — due  to  organic  changes  in 
the  brain. 

Mania  is  very  frequently  a  symptom  of  organic  disease 
of  the  brain  (intoxication,  paretic  dementia)  ;  if  it  does  not 
indicate  organic  cerebral  disease,  it  is  next  most  frequently 
a  sign  of  degenerate  insanity — recurrent,  periodic  or  cir- 
cular, or  an  episode  of  epileptic  insanity. 

Of  the  simple  forms  of  insanity,  emotional  depression  is 
the  most  benign  as  such,  and  also  the  least  open  to  suspicion 
of  being  a  functional  sign  of  marked  degeneracy.  But  it 
also  occurs  in  the  course  of  degenerate  insanity,  and  also  as 
one  of  the  symptoms  of  organic  insanity.  However,  as  will 
be  seen  later,  melancholia  like  all  the  general  functional  dis- 
turbances that  constitute  the  insane  state  must  be  judged 
with  reference  to  its  origin,  its  quality,  its  course,  and  its 
relation  to  other  mental  symptoms. 

There  is  a  relation  between  the  emotional  and  the  intel- 
lectual symptoms  of  insanity  that  is  worthy  of  special  at- 
tention,— it  is  a  psychologic  law.  It  will  be  understood  best 
by  examples.  One  learns  that  he  has  fallen  heir  to  a  great 
fortune;  the  natural  reaction  is  that  of  pleasure  (exalta- 
tion). Let  the  news  prove  false  and  the  reaction  is  that 
of  depression  (melancholy).  This  shows  how  idea  may 
give  rise  to  an  emotional  reaction.  On  the  other  hand,  a 
primary  emotional  state  may  be  the  origin  of  the  intellectual 
state.  No  better  example  of  this  can  be  cited  than  the  usual 
effect  of  alcohol :  the  emotional  state  induced  is  primarily 
gay;  as  a  result,  things  are  of  a  rosy  hue  and  immediately 
ideas  become  clearer  and  brighter  and  not  in  accord  with 
facts — delusional.  When  the  primary  emotional  effect  of 
the  alcohol  subsides  there  is  emotional  depression  with  a 
consequent  delusional  (intellectual)  attitude  of  mind.    Like- 


110  OUTLINES   OF   PSYCHIATRY. 

wise,  in  insanity  primary  emotional  symptoms  may  be  the 
basis  of  intellectual  symptoms;  primary  intellectual  symp- 
toms may  be  the  basis  of  emotional  symptoms.  It  is  there- 
fore very  important  to  determine,  if  possible,  the  causal 
order  of  relation  between  emotional  and  intellectual  symp- 
toms— to  determine  what  is  secondary  in  order  of  origin. 
In  other  words  an  insane  person  may  be  depressed  or  excited 
because  he  entertains  delusions;  or  he  may  entertain  delus- 
ions because  he  is  depressed  or  excited.  From  a  practical 
standpoint  this  distinction  is  important  because  primary 
emotional  states  as  a  cause  of  intellectual  disorder  are  far 
more  favorable  than  primary  intellectual  states  as  a  cause 
of  emotional  disorder. 


LESSON  XV. 

Emotional  Depression. 
(Melancholia.) 

The  most  prominent  characteristic  of  melancholia  is  sad- 
ness; whenever  this  symptom  occurs,  we  speak  of  melan- 
choly, and  of  melancholia  as  a  form  of  insanity  if  the 
emotional  depression  be  pathologic  and  not  a  complication 
of  some  other  form  of  mental  disease. 

The  pathologic  state  of  melancholia  is  best  understood 
by  comparing  it  with  normal  emotional  depression  that 
results  from  some  adequate  cause.  When  one  is  suddenly 
striken  by  some  great  sorrow,  a  state  of  depression  takes 
possession  of  the  whole  mental  being  and  all  activity  is 
interfered  with,  consciousness  being  entirely  filled  with  a 
painful  state  of  feeling  that  inhibits  thought  unrelated  to 
it ;  ordinary  normal  moral  interests  pass  unregarded ;  the 
actions,  attitude,  and  facial  expression  are  in  harmony  with 
the  emotional  state — physical  inactivity,  lack  of  muscular 
tone,  relaxed  features ;  there  is  desire  for  solitude  and  retire- 
ment from  all  that  is  out  of  harmony  with  the  emotional 
state;  the  organic  functions  become  sluggish  and  appetites 
are  lost.  A  certain  egotism  is  thus  apparent,  and  often,  if 
not  always,  the  sadness  is  purely  selfish  in  the  sense  that  it 
arises  out  of  a  moral  wound  to  the  ego.  This  normal  de- 
pressive reaction  is  of  comparatively  short  duration,  and 

in 


112  OUTLINES  OF  PSYCHIATRY. 

the  sufferer  has  enough  reason  and  force  to  try  to  over- 
come the  depression  by  seeking  active  distraction  from  the 
pain,  in  which  he  finally  succeeds  completely. 

A  state  of  normal  depression  may  be  the  beginning  of  a 
pathologic  state  of  melancholia,  or  the  depression  may 
develop  without  apparent  or  adequate  cause  in  external  con- 
ditions. The  psychic  elements  that  render  it  possible  to 
decide  that  depression  is  pathologic  are:  (1)  absence 
of  adequate  external  cause;  (2)  absence  of  reaction  to  in- 
fluences that  modify  or  overcome  normal  mental  depression ; 
(3)  exaggeration  in  intensity  and  duration  of  the  elements 
that  characterize  normal  depression;  (4)  the  expressed  feel- 
ing of  helplessness  and  hopelessness  of  relief  of  the  painful 
state,  for  normal  depression  is  never  felt  as  a  hopeless  state ; 
(5)  absolute  self -concentration  in  the  depression;  (6)  ten- 
dency to  project  mentally  the  subjective  sadness  to  include 
others — relatives  and  friends  and  finally  the  whole  world ; 
(7)  consciousness  of  mental  disease  often  expressed;  (8) 
self-reproach. 

If  melancholia  has  begun  in  normal  depression,  the 
transition  from  it  is  marked  by  the  development  of  some  of 
the  characteristics  enumerated. 

Simple  melancholia  is  pathologic  depression  and 
mental  inhibition  without  delusions  and  hallucinations.  It 
presents  many  degrees  of  intensity  and  may  be  the  prelim- 
inary stage  of  melancholia  with  delusions,  etc.  It  is  the 
most  common  form  of  mental  disease.  When  of  spontme- 
ous  origin  and  recurrent  it  is  highly  indicative  of  a  mild 
degree  of  degeneracy. 

Melancholia  with  delusions  is  pathologic  depres- 
sion accompanied  by  elementary  anomalies  of  the  senses 
and  the  intellect.     It  is  the  form  commonly  met  in  hospitals. 


EMOTIONAL  DEPRESSION.  113 

for  the  insane.  Clinically,  several  forms  are  to  be  dis- 
tinguished in  accordance  with  the  predominance  of  certain 
symptoms.  Thus,  we  have  a  passive  melancholia  and  an 
active  melancholia,  a  moral  melancholia  and  an  hypochon- 
driac melancholia. 

The  type  in  some  cases  may  change  with  the  continuance 
of  the  disease;  for  example,  an  active  melancholia  may  be- 
come passive;  the  mental  symptoms  may  combine  hypo- 
chondriac and  moral  delusions. 

When  depression  and  delusions  co-exist,  in  order  to 
make  a  diagnosis,  it  is  necessary  to  determine  the  relation 
between  them;  for  depression  may  precede  and  be  the 
cause  of  delusions,  or  delusions  may  precede  and  be  the 
cause  of  depression.  When  unable  to  determine  immedi- 
ately this  relation,  we  must  remain  in  doubt  and  wait  for 
time  or  the  course  of  the  disease  to  enlighten  us. 

Melancholia,  in  any  case,  may  be  the  manifestation  of 
a  periodic,  recurrent,  or  circular  psychosis,  and  this  point 
can  only  be  determined  with  certainty  by  the  history  of  pre- 
vious attacks  or  the  course  of  the  disease.  It  may  be  a 
mental  symptom  of  organic  cerebral  disease. 

The  mental  symptoms  of  a  typical  case  of  melancholia 
with  delusions  present  two  stages  of  development,  one  of 
simple  initial  depression,  and  a  second  delusional  state.  The 
initial  stage  may  be  long  or  give  place  quickly  to  the  sec- 
ond. 

Initial  stage  of  depression  :  the  patient  is  sad,  inac- 
tive, sick,  disinterested,  neglects  or  abandons  his  usual  duties, 
is  careless  of  personal  appearance,  and  seeks  to  avoid  con- 
tact with  others ;  or  if  he  seeks  consolation,  it  is  to  express 
his  feelings  of  ill-defined  fear,  or  to  ask  protection  from 
his  thoughts  of  death  or  suicide.     The  persistence  of  this 


114  OUTLINES   OF   PSYCHIATRY. 

depression  leads  to  a  subjective  search  for  its  cause,  and 
this  is  found  in  his  own  moral  delinquencies  or  guilt.  He 
is  justly  sad  as  the  consequence  of  his  own  acts — he  has 
been  a  liar ;  he  has  been  a  sinner ;  he  has  committed  crimes 
against  God  and  man ;  his  sadness  is  a  moral  punishment  to 
be  increased  by  legal  punishment;  his  life  now  and  here- 
after has  been  ruined  by  his  own  acts,  and  all  hope  is 
destroyed.  Hallucinations  are  added :  he  sees  the  officers  of 
the  law;  hears  his  prospective  punishment  and  torture 
described ;  sees  his  coffin  prepared ;  hears  preparation  for  his 
torture.  The  punishment  is  even  extended  to  include  wife 
and  children,  or  the  whole  world  is  to  suffer  for  his  crimes. 
The  feeling  of  horror  may  induce  a  passive  state  (passive 
melancholia)  or  even  stupor,  or  an  agitated  state  of  violent 
despair  (active  melancholia). 

In  hypochondriac  melancholia,  the  fears  entertained 
are  about  the  patient's  own  body.  He  fears  for  his  health 
and  attributes  imaginary  or  actual  physical  symptoms  to  his 
own  sins.  The  cause  of  his  suffering  is  onanism,  syphilis, 
or  a  life  of  excesses.  He  develops  corresponding  hallucina- 
tions :  he  sees  his  body  rotting  away ;  smells  odors  of  decay ; 
feels  that  his  intestines  are  in  a  state  of  gangrene;  has  com- 
municated his  disease  to  everybody.  Here  there  is  always 
the  element  of  self-accusation,  as  in  other  forms  of  mel- 
ancholia. 

Suicidal  impulse  is  the  natural  result  of  melancholia,  and 
it  is  the  greatest  danger  in  the  disease;  murder  of  children 
or  relatives  may  be  the  result  of  delusions,  but  the  sacrifice 
of  others  is  in  obedience  to  the  desire  to  save  them  from  suf- 
fering. In  agitated  melancholia  acts  of  personal  violence 
may  be  clue  to  wild  impulse  of  self-defense.  No  depressed 
patient  should  ever  be  trusted;  for  the  impulse  to  suicide 


EMOTIONAL  DEPRESSION.  115 

occurs  in  almost  every  case,  and  if  absent  may  appear  at 
any  moment.  Fear  of  death  is  no  guarantee  against  sui- 
cide ;  and  denial  of  intention  may  be  preparation  for  suicide. 

Special  symptoms  of  melancholia  require  discussion  in 
detail. 

Hallucinations,  etc.,  are  of  a  fearful  or  depressive 
character  in  harmony  with  the  emotional  depression  and  the 
corresponding  delusions.  They  occur  in  one  or  in  several 
of  the  senses  at  the  same  time.  The  patient  hears  reproach- 
ful voices ;  sees  those  that  come  to  arrest  him,  or  the  fire 
prepared  to  burn  him.  He  smells  or  tastes  poison  in  his 
food ;  noxious  gases  are  forced  into  his  room  at  night,  to 
poison  or  suffocate  him.  If  hypochondriac,  bodily  feelings 
are  misinterpreted  as  signs  of  foul  disease  or  decay;  parts 
of  the  body  have  changed  to  glass  or  stone;  the  alimentary 
tract  has  become  permanently  obstructed,  etc. 

The  delusions  may  be  in  direct  relation  with  errors  of 
the  senses,  or  exist  independently  of  them;  but  they  are 
always  of  a  depressive  nature,  and  always  accompanied  by 
self-accusation.  They  concern  the  past  as  well  as  the  pres- 
ent and  future.  If  the  patient  is  persecuted  he  deserves  his 
persecution  even  though  he  may  attempt  to  escape  it. 

Memory  remains  practically  undisturbed,  except  in  pos- 
sible periods  of  very  great  excitement  or  profound  stupor. 

Speech  is  slow,  low,  and  often  tremulous.  The  voice 
may  be  only  a  whisper.  The  patient  may  speak  in  monosyl- 
lables or  be  silent  and  give  only  slight  signs  of  understand- 
ing. He  may  show  only  by  change  of  facial  expression  or 
slight  movement  or  signs  that  he  understands.  Speechless- 
ness may  be  due  to  delusions  and  hallucinations — he  is  com- 
manded as  a  punishment  not  to  speak;  he  will  be  punished 
for  speaking;  he  cannot  speak  without  sinning,  etc. 


116  OUTLINES  OF    PSYCHIATRY. 

Self-mutilation  and  suicide  are  always  to  be  feared. 
Mutilation  is  due  to  delusion.  A  patient  may  castrate  him- 
self or  cut  off  his  genitals  because  of  imaginary  sexual  sin. 
"If  thy  right  hand  offend  thee,  cut  it  off"  may  be  a  cause 
of  self-mutilation  in  melancholia  with  religious  coloring. 

Suicide  is  attempted  in  many  ways — by  starvation,  by 
immersing  the  head  in  a  pail  of  water,  by  opening  a  vessel 
with  a  needle,  by  hanging,  etc.  The  ingenuity  and  cunning 
of  melancholiacs  under  surveillance  to  attain  their  end  is  sur- 
prising, and  hence  the  necessity  for  the  most  minute  and 
systematic  care  to  prevent  suicide. 

Often  the  patient  is  physically  passive,  but  there  may  be 
a  marked  state  of  negation  and  resistance  to  all  efforts  made 
to  excite  movement.  Voluntary  movements  are  slow,  often 
undecided,  and  initiated  movements  often  are  not  com- 
pleted. The  attitude  is  relaxed,  and  the  facial  expression 
sad. — the  brow  contracted,  the  head  bent  down,  the  eyes  par- 
tially closed.  If  agitated,  the  patient  may  walk  about  con- 
stantly wringing  his  hands  and  bewailing  his  fate.  A  state 
of  hypertonicity  of  muscles  is  occasionally  observed. 

Refusal  of  food  is  a  common  symptom  in  melancholia. 
It  may  be  due  to  lack  of  appetite,  gastro-intestinal  dis- 
ease, and  the  general  inactivity ;  to  fear  of  poison ;  to  fear 
of  sinning  by  eating;  or  to  a  desire  to  die. 

Sleeplessness  is  a  very  common  and  obstinate  symp- 
tom at  the  height  of  the  disease.  On  the  other  hand,  som- 
nolence may  be  one  of  the  striking  symptoms  in  the  early 
stage  of  simple  depression,  explained  by  the  desire  of  the 
patient  to  escape  from  his  melancholy. 

The  circulation  is  altered.  The  pulse  is  often  slow 
and  hard  and  small,  the  extremities  blue  and  cold  and  some- 
times edematous.     The  state  of  the  circulation  is  probably 


EMOTIONAL  DEPRESSION.  117 

responsible  for  the  common  feeling  of  precordial  distress 
or  anxiety,  which  may  reach  such  intensity  as  to  cause  an 
outbreak  of  violent  wild  despair  called  raptus  melancholicus. 

Respiration  in  profound  melancholia  is  slow  and  super- 
ficial. 

The  Tongue  is  coated,  and  the  lips  and  teeth  may  be 
covered  with  sordes  in  extreme  cases. 

The  urine  is  diminished  in  quantity  and  the  solids  are 
below  the  normal  amount. 

Etiology,  etc.  Melancholia  in  all  its  forms  is  more 
frequent  in  women  than  in  men.  It  occurs  at  all  ages,  but 
is  most  frequent  between  the  ages  of  twenty  and  thirty  years. 
Puberty  and  old  age  have  an  unfavorable  influence  on  its 
course.  Direct  causes  are  most  frequently  of  a  moral  kind, 
but  predisposition  has  much  influence  even  here,  and  it  is  pre- 
ponderant in  cases  of  simple  melancholia. 

The  beginning  of  the  disease  is  usually  gradual,  as  is 
also  the  attainment  of  the  height  of  the  disease.  A  sudden 
outbreak  and  rapid  attainment  of  great  intensity  commonly 
indicate  that  the  disease  is  not  uncomplicated ;  that  it  is 
probably  of  a  periodic  or  circular  nature.  The  course  is 
slow  with  remissions  and  exacerbations,  and  if  terminating 
favorably  the  return  to  health  is  gradual.  A  sudden  ter- 
mination in  lucidity  is  a  sign  of  bad  omen — that  the  disease 
is  periodic  or  circular. 

The  duration  of  melancholia  is  usually  a  few  months, 
often  a  year  or  more,  and  it  may  continue  several  years  and 
end  in  recovery. 

The  possible  terminations  are : 

(1)  Recovery,  which  takes  place  in  60  per  cent  or  70 
per  cent  of  all  cases  under  favorable  treatment.    Simple  mel- 


118  OUTLINES   OF   PSYCHIATRY. 

ancholia  almost  always  ends  in  recovery,  but  it  is  a  recur- 
rent disease. 

(2)  Secondary  dementia  is  the  result  in  cases  that 
have  not  terminated  in  recovery  or  death :  dementia  may  be 
slight  (recovery  with  defect),  or  the  secondary  insanity  may 
be  a  marked  dementia,  or  a  dementia  with  delusions  more 
or  less  systematized — a  secondary  paranoia. 

(3)  Death  from  suicide,  exhaustion,  or  secondary 
physical  disease,  especially  tuberculosis. 

The  diagnosis  of  melancholia,  as  already  indicated, 
depends  primarily  on  the  existence  of  emotional  depression, 
intellectual  inhibition,  and  the  proof  that  depression  is  pri- 
mary and  not  a  secondary  result  of  delusions.  Self-accusa- 
tion is  almost  pathognomonic  of  melancholia. 

The  differential  diagnosis  must  be  made  first  with  ref- 
erence to  psychoses  due  to  organic  causes  (intoxication, 
gross  cerebral  disease) . 

Melancholia  due  to  alcohol  is  of  short  duration,  and 
usually  the  signs  of  alcoholism  may  be  discovered. 

Paretic  dementia  is  differentiated  from  melancholia  by 
the  signs  of  the  organic  disease : — leucocytosis,  etc.,  of  the 
cerebro-spinal  fluid ;  anomalies  of  the  pupil ;  certain  forms  of 
tremor ;  pathologic  alterations  of  the  deep  reflexes ;  dementia 
(amnesia). 

Paranoia,  if  showing  depression,  may  usually  be  distin- 
guished by  the  fact  that  delusions  are  primary;  that  perse- 
cution and  fears  are  expressed  as  unmerited  in  contrast  with 
the  self-accusation  of  the  melancholiac. 

The  passive  state  of  hallucinatory  delirium  is  to  be  dis- 
tinguished by  the  variations  of  the  mental  symptoms  and 
the  absence  of  connected  states  of  self-consciousness. 


EMOTIONAL  DEPRESSION.  119 

Acute  dementia  presents  certain  difficulties,  but  usu- 
ally the  facial  expression  of  the  passive  melancholiac  suf- 
fices to  show  that  his  passivity  is  due  to  ideas,  rather  than 
to  absence  of  mental  activity. 

Stuporous  melancholia  cannot  be  differentiated  from  de- 
mentia except  by  the  history. 

The  differentiation  of  melancholia  from  periodic  and  cir- 
cular insanity  can  only  be  made  with  certainty  by  the  his- 
tory and  observation  of  the  patient. 

The  prognosis  of  melancholia  is  more  or  less  favorable, 
as  is  shown  by  the  percentage  of  recoveries. 

Treatment.  The  first  indication  to  meet  in  the  treat- 
ment of  melancholia  and  emotional  depression,  in  general, 
is  the  prevention  of  suicide,  possible  in  any  state  of  depres- 
sion, and  highly  possible  in  a  frank  melancholia.  The  ful- 
fillment of  this  indication  is  best  obtained  by  never  leaving 
the  patient  alone,  and  having  a  perfect  appreciation  of  the 
cunning  and  violence  such  patients  employ  to  obtain  the 
desired  end. 

The  second  question  is  whether  it  be  best  to  treat  the 
patient  at  home,  in  an  ordinary  hospital,  or  in  an  asylum. 
If  money,  room,  and  all  the  needed  nurses  of  experience  be 
available,  there  need  be  no  doubt  about  choosing  the  home  or 
a  hospital,  at  least  during  the  first  few  months;  for  thus  the 
medical  indications  can  be  met  without  incurring  or  risking 
the  odium  that  invariably  attaches  to  a  sojourn  in  any 
asylum,  and  without  the  prejudice  to  the  patient's  welfare 
occasioned  by  the  necessary  legal  procedure  for  commitment. 
In  the  absence  of  such  means  or  with  prolongation  of  the 
condition,  the  asylum  is  indicated.  It  is  assumed,  also,  that 
in  home-treatment,  there  is  a  perfect  understanding  of  psy- 


120  OUTLINES   OF   PSYCHIATRY. 

chiatry  on  the  part  of  the  medical  attendant  and  much  pa- 
tience on  the  part  of  the  relatives. 

The  first  direct  medical  indication  is  rest  in  bed  with 
care  to  maintain  body-heat.  No  persistent  effort  should 
be  made  to  "wake  up"  the  patient  or  to  argue  him  out  of  his 
depression  or  delusions.  He  should  be  allowed  to  under- 
stand by  a  consistent  manner,  that  he  is  considered  a  sick 
person. 

Sleeplessness  should  be  treated  by  warm  baths  and  alco- 
holic stimulants,  and  ultimately  by  bromides,  sulphonal, 
trional,  and  chloral  hydrate ;  no  drug  should  be  used  exclus- 
ively, except  for  the  best  of  reasons.  The  milder  the  means 
that  attain  the  end  the  better. 

The  loss  of  appetite  and  the  constant  loss  of  weight  call 
for  special  attention  to  food  and  the  sufficient  ingestion  of 
liquids.  It  is  not  well  to  allow  a  patient  to  persist  in  taking 
insufficient  food  and  drink,  but  to  proceed  (after  three 
or  four  days)  to  the  forcible  ingestion  of  milk  and  eggs, 
and  to  look  to  the  state  of  digestion  and  evacuation. 
Persistence  in  fasting  for  a  longer  time  may  cause  a  fatal 
termination,  always  after  fourteen  days.  It  may  be  neces- 
sary to  administer  medicines  by  force,  as  they  are  often  re- 
fused like  food,  and  the  two  can  be  given  at  the  same  time. 
If  evacuants  do  not  act  well,  recourse  must  be  had  to  enemas 
(glycerine).     Nutrient  enemas  are  only  of  temporary  use. 

Forced  EEEding  is  an  operation  long  since  simplified  and 
easily  carried  out  in  spite  of  the  greatest  resistence  without 
the  slightest  harm  to  the  patient.  The  forcible  use  of  a 
stomach-tube  passed  by  the  mouth  should  be  condemned 
because  of  the  brutality  often  necessary  for  its  introduction 
with  patients  that  resist  by  closure  of  the  mouth.  A  small 
(No.  10)   soft  rubber  catheter  passed  into  the  oesophagus 


EMOTIONAL  DEPRESSION.  121 

through  the  nares  is  infinitely  easier  and  always  efficacious 
as  a  means  of  passing  liquid  food  to  the  stomach.  The 
apparatus  necessary  is  an  ordinary  bulb  syringe,  a  syringe 
operated  by  air  pressure  (Hall  Health  Syringe),  or  a  simple 
douche  apparatus  (avoid  too  rapid  passage  of  the  liquid  by 
raising  the  reservoir  only  moderately  high).  The  tube 
leading  from  the  syringe  is  inserted  into  the  catheter  either 
before  or  after  its  introduction  through  the  nares  into  the 
oesophagus. 

There  are  certain  precautions  to  be  taken  in  the  intro- 
duction of  the  catheter.  To  be  sure  that  it  has  not  entered 
the  larynx,  it  is  necessary  to  observe  the  breathing  and  in- 
duce the  patient  to  speak  if  possible.  There  is  often  a  cer- 
tain degree  of  anesthesia  of  the  larynx  which  allows  the 
passage  of  the  tube  without  causing  cough.  However,  if 
the  tube  has  passed  into  the  larynx,  the  respiration  is  always 
embarrassed.  Movements  of  vomiting,  if  they  occur, 
should  not  be  allowed  to  hinder  the  operation.  Some  pa- 
tients are  very  skillful  in  bringing  the  tube  forward  into  the 
mouth  as  it  passes  the  pharynx ;  a  little  care  overcomes  this 
obstacle.  In  case  of  doubt  of  the  position  of  the  tube,  it 
should  be  withdrawn,  and  reintroduced.  Care  should  be 
taken  to  avoid  losing  the  tube  in  the  stomach.  It  is  only 
necessary,  in  order  to  avoid  this,  to  look  to  the  security  of 
the  tube  at  its  attachment  to  the  syringe.  If  a  patient  resist 
feeding,  a  very  practical  way  of  overcoming  this  with- 
out harm  to  the  patient,  is  to  seat  him  in  an  arm- 
chair and  pass  a  strong  stick  over  his  knees  and  under  the 
arms  of  the  chair ;  an  assistant  on  each  side  holds  an  arm 
and  at  the  same  time  the  chair  is  inclined  backward  raising 
the  patient's  feet  from  the  floor.  The  operator  places  him- 
self behind  and  controls  the  head  by  placing  the  left  hand 


122  OUTLINES  OF    PSYCHIATRY. 

under  the  chin  and  pressing  the  head  backwards  against  his 
chest;  with  the  right  hand  the  tube  may  then  be  readily 
introduced  in  spite  of  jerking  of  the  head.  A  patient  may 
be  fed  in  bed  without  difficulty.  The  resistence  of  a  patient 
usually  disappears  when  he  is  convinced  that  it  is  useless 
and  the  intentions  of  the  physician  are  harmless.  It  is  neces- 
sary to  watch  a  patient  after  feeding  to  prevent  voluntary 
vomiting  of  the  food  ingested.  A  patient  should  be  fed 
twice  daily  at  least,  and  oftener  if  indicated. 

The  drug  almost  always  indicated  in  melancholia  is 
opium  or  some  one  of  its  derivatives.  It  may  be  given  by 
the  stomach  or  hypodermatically.  The  latter  method  is  pref- 
erable for  reasons  of  exactness  and  to  avoid  disturbance  of 
digestion  and  possible  accumulation  of  the  drug.  The  best 
form  is  the  aqueous  extract  of  opium  hypodermatically; 
morphine  and  codeine  prove  useful  in  some  cases.  There  is 
no  danger  of  forming  a  habit,  if  the  patient  be  kept  in  ignor- 
ance. The  dose  cannot  be  defined.  At  first  it  should  be 
very  small  and  gradually  increased  with  all  precautions, 
until  depression  is  favorably  influenced.  By  the  mouth  it 
may  be  necessary  to  increase  to  fifteen  grains  per  day  of 
opium,  or  its  equivalent.  It  should  never  be  stopped  sud- 
denly, but  withdrawn  gradually,  as  in  an  opium-cure.  If 
administered  by  the  stomach,  hydrochloric  acid  should  also 
be  given ;  if  it  cause  vomiting,  atropine  may  be  added. 

Opium  is  almost  a  specific  in  depression.  Sometimes  it 
acts  like  magic.  It  is  useful  in  almost  all  forms  of  emo- 
tional depression.  To  do  any  good  it  must  be  used  freely, 
though  always  with  discretion. 

The  drug  treatment  in  general  of  melancholia  finds  its 
indications  in  physical  conditions  which  need  no  further  ex- 
planation.    In  the  first  few  weeks  or  months  every  effort 


EMOTIONAL  DEPRESSION.  123 

should  be  made  to  restore  the  physical  condition  by  observing 
the  requirements  of  rest,  food,  and  meeting  all  general  indi- 
cations. 

The  psychic  condition  of  the  patient  must  never  be  left 
out  of  account.  Tactful  appreciation  of  the  patient's  depres- 
sion and  delusions  should  be  shown  in  gentle  remonstrance 
and  argument.  Argument  though  seemingly  useless,  and 
harmful  if  persistent  or  peremptory,  should  never  be  en- 
tirely abandoned;  the  patient  should  never  be  left  inactive 
or  without  signs  about  him  of  interest  in  his  welfare.  A 
patient  left  plunged  in  melancholy,  with  all  bodily  needs 
cared  for,  but  isolated  by  the  indifference  of  those  around 
him,  is  destined  to  pass  into  dementia.  Thus,  after  the 
earlier  signs  of  exhaustion  have  disappeared  and  there  is 
some  evidence  of  physical  improvement,  the  patient  should 
be  removed  from  bed  and  gently  encouraged  to  take  inter- 
est in  companionship  and  in  exercise  in  the  open  air.  Isola- 
tion is  good  only  for  acute  conditions. 

In  general,  physical  improvement  without  signs  of  men- 
tal improvement  is  of  bad  omen;  and  sudden  improvement, 
unless  as  a  result  of  opium,  without  physical  improvement, 
is  also  suspicious ;  the  two  should  go  hand  in  hand,  though 
mental  improvement  may  follow  physical  change  for  the 
better  at  a  considerable  interval. 

In  cases  treated  in  an  asylum,  it  is  necessary  to  take  into 
account  the  possible  effect  of  homesickness,  etc.  In  certain 
cases  recovery  is  completed  by  placing  the  convalescent 
patient  in  his  former  surroundings.  Much,  therefore,  de- 
pends upon  the  judgment  of  the  physician. 

In  general  it  may  be  said  that  travel,  change  of  scene, 
and  efforts  to  distract  the  melancholic  are  decidedly  mis- 
placed in  the  early  weeks  of  the  disease. 


LESSON  XVI. 

Emotional  Exaltation. 

(Mania.) 

The  principal  characteristic  of  mania  is  emotional  excite- 
ment expressed  in  abnormally  increased  physical  and  mental 
activity.  Whenever  this  symptom  occurs  we  say  the  patient 
is  maniacal.  It  constitutes  a  simple  form  of  insanity  if  it 
be  pathologic  and  not  a  complication  of  some  other  form  of 
mental  disease. 

Mania,  as  a  simple  functional  psychosis,  is  very  rare,  but 
maniacal  patients  are  very  common. 

Usually  a  definition  of  mania  is  made  to  include  emo- 
tional gaiety  or  pi  en  sure,  as  a  characteristic  in  contrast  with 
the  sadness  of  melancholia ;  this  is  an  error  in  the  sense  that 
gaiety  of  sentiment,  while  frequent  in  maniacal  states,  is  far 
from  being  constant ;  the  emotional  state  is  changeable,  just 
as  the  thoughts  are  changeable. 

The  real  contrast  of  melancholia  and  mania  lies  in  the 
contrast  of  monotony  of  emotion  and  ideas  in  the  one  with 
the  rapid  variation  of  emotion  and  ideas  in  the  other. 

Any  emotion  may  occur  in  mania — gaiety,  sadness,  anger 
■ — but  no  emotion  lasts  long;  feeling  runs  through  all  its 
modes  of  expression  with  comparative  rapidity,  and  thought 
and  action  keep  pace  with  it. 

Melancholia   is   a   condition   of   mental   monotony   that 

124 


EMOTIONAL    EXALTATION.  125 

passes  through  a  period  of  confinement  to  a  single  kind  of 
thought  and  feeling  to  absolute  arrest  of  mental  activity. 
Mania  is  a  condition  of  acceleration  of  the  play  of  thought 
and  feeling  that  passes  through  a  period  of  excitement,  with 
momentarily  expressed  thoughts  and  feelings,  absolute  in- 
coherence of  ideas  and  emotions,  and  finally  even  to  arrest 
of  mental  activity  (exhaustion). 

It  is  difficult  or  impossible  to  determine  whether  the 
emotional  state,  in  a  case  of  mania  has  acted  to  cause  accel- 
eration of  ideas,  or  vice-versa;  and  the  solution  of  the  ques- 
tion has  less  practical  importance  than  in  the  case  of  melan- 
cholia ;  however,  it  is  true  that  emotional  excitement  of  a 
pleasurable  kind  increases  the  play  of  ideas,  and  increased 
play  of  ideas  may  cause  a  pleasurable  emotion. 

The  best  artificial  example  of  mania  is  affordedjby  the 
excitement  observed  at  a  certain  stage  of  alcoholic  intoxi- 
cation :  when  the  convivial  person  begins  to  feel  the  poison, 
he  shows  it  in  that  he  becomes  abnormally  wide-awake,  see- 
ing all  and  reacting  to  everything  around  him ;  he  grows 
more  talkative  and  his  words  are  accompanied  by  more  and 
more  lively  gestures ;  his  opinions  grow  more  and  more  posi- 
tive; he  becomes  more  and  more  argumentative;  his  com- 
passion or  anger  arises  at  the  mere  idea  of  suffering  or  op- 
position; he  is  moved  to  tears  or  revengeful  anger  for  the 
sake  of  others ;  an  argument  excites  his  ridicule  and  at  last 
his  anger,  and  perhaps  he  goes  to  the  extent  of  physical 
violence  or  of  blind  impulsive  murder  at  the  provocation  of 
argumentative  opposition;  finally  he  passes  into  a  state  of 
incoherence  of  ideas  and  feelings. 

Mania,  as  a  functional  psychosis,  presents  several  pos- 
sible stages.  Usually  it  is  preceded  by  a  period,  more  or 
less  prolonged,  of  general  malaise,  mental  dullness,  loss  of 


126  OUTLINES  OF   PSYCHIATRY. 

appetite,  and  imperfect  sleep.  This  may  be  called  the  initial 
stage  of  depression,  which  differs  in  no  essential  way  from 
the  beginning  of  melancholia.  More  or  less  suddenly  the 
clinical  picture  changes.  The  ideas  and  feelings  show  a 
livelier  play.  The  patient  is  gay ;  his  ideas  are  innumerable ; 
and  his  actions  follow  his  feelings  and  thoughts  without  re- 
flexion. He  becomes  witty  and  superior  to  his  companions. 
He  becomes  more  charitable,  more  compassionate,  more 
irritable,  more  uncompromising,  less  open  to  argument,  im- 
patient of  control  or  of  obstacles  of  any  kind;  all  is  rosy 
or  momentarily  quite  the  opposite.  Personal  modesty  dis- 
appears; grand  ideas  are  expressed;  action  and  thought  be- 
come indicative  of  belief  in  the  impossible,  in  the  utility  and 
perfection  of  all  the  patient  thinks  and  does.  The  excite- 
ment leads  to  physical  restlessness  of  all  kinds,  so  that  dis- 
sipation and  wandering  about  without  reference  to  social 
conventions,  become  the  striking  signs  of  the  abnormality. 

The  physical  accompaniments  are  bright  eyes,  increased 
circulation  shown  in  a  quick,  frequent  pulse,  and  flushed 
face. 

In  the  beginning  the  appetites  are  increased,  but  later, 
if  confusion  occur,  the  changing  ideas  give  no  time  for  the 
satisfaction  of  them.  The  patient  does  not  eat  for  lack  of 
time,  and  neglects  all  conventionalities.  The  physical  con- 
dition deteriorates  rapidly  in  spite  of  seemingly  sufficient 
food,  owing  to  excessive  physical  activity  and  sleeplessness, 
and  a  state  of  physical  exhaustion  is  threatened  or  attained. 

Mania  may  present  a  stage  of  depression,  a  stage  of 
exaltation,  a  stage  of  fury.  The  initial  stage  of  depression 
can  but  rarely  be  immediately  estimated  at  its  value;  the 
stage  of  exaltation  is  only  a  degree  of  excitement  less  than 
that  of  fury  and  separated  from  it  only  by  conventional  esti- 
mation of  the  degree  of  excitement.     Incoherence  of  ideas 


EMOTIONAL   EXALTATION.  127 

may  be  apparent  long  before  a  state  of  fury  is  reached.  In 
the  state  of  fury  the  patient  is  constantly  in  action,  weeping, 
crying,  shouting,  dancing,  striking,  tearing,  and  paying  no 
attention  to  the  calls  of  nature.  Grand  ideas  are  the  rule; 
sleeplessness  is  constant.  Insufficient  taking  of  food  and 
drink  may  call  for  forced  feeding  as  in  melancholia.  The 
lack  of  sense  of  fatigue  and  of  perception  of  heat  and  cold 
is  remarkable. 

Mania  gravis  (acute  delirious  mania.  Bell's  mania)  is 
the  ultimate  stage  of  aggravation  of  mania ;  it  is  often  a  com- 
plication in  the  sense  that  it  is  reached  rapidly,  accompanied 
by  fever,  muscular  twitchings,  and  grinding  of  the  teeth.  It 
is  regarded  as  due  to  an  infection. 

Mania  as  a  symptom  is  always  of  very  doubtful  signifi- 
cance ;  it  should  always  be  regarded  as  possibly  indicative  of 
more  than  functional  disturbance;  for  most  frequently  it  is 
a  symptom  of  degenerate  or  organic  cerebral  conditions. 

Mild  maniacal  exaltation  is  practically  always  a  sign  of 
degeneracy,  when  it  cannot  be  proved  to  be  due  to  some  ex- 
citing cause — intoxication. 

Pronounced  mania  is  usually  a  recurrent  form  of  (de- 
generate) mental  disease.  Sudden  mania  with  sudden  sub- 
sidence is  either  recurrent  or  periodic,  a  phase  of  circular 
insanity,  or  allied  to  epilepsy,  intoxication,  etc. 

Mania  gravis  (Bell's)  is  either  aggravation  of  an  or- 
dinary mania  (accidental  infection)  or  due  to  primary  infec- 
tion.   It  is  classed  as  an  organic  insanity. 

The  special  symptoms  of  mania  require  some  detailed 
consideration. 

Hallucinations  are  rare  symptoms  in  mania,  except 
in  its  most  active  stage;  illusions,  on  the  contrary,  are  very 
common  in  the  disease.     Both  illusions  and  hallucinations 


128  OUTLINES  OF   PSYCHIATRY. 

are  very  changeable,  in  consonance  with  the  fundamental 
state  of  mind.  Errors  of  a  visual  kind  are  the  most  fre- 
quent, though  errors  of  none  of  the  senses  are  excluded. 

A  feeling  of  sickness  (mental  or  physical)  in  mania  is 
never  expressed ;  the  patient  has  a  feeling  of  unexampled 
well-being,  often  in  contrast  with  the  physical  condition  or 
actual  physical  disease  or  injury  present.  This  is  in  accord 
with  the  absence  of  sense  of  fatigue  so  characteristic  of 
mania,  and  the  frequent  declaration  of  a  feeling  of  more 
than  perfect  health. 

Sexual  feelings  are  usually  increased,  and  often  shame- 
lessly expressed  in  onanism  and  sexual  approach  to  the 
opposite  sex,  or  in  obscene  language.  With  ethical  feeling 
lost,  offenses  against  modesty  and  sexual  reserve  (naked- 
ness, sexual  exhibition,  open  performance  of  acts  of  nature, 
etc.)  are  frequent.  Seemingly  innocent  girls  become  erotic 
in  language  to  a  degree  which  proves  that  it  is  impossible  to 
shield  the  young  from  knowledge  of  obscenity. 

The  process  of  Thought  is  greatly  facilitated,  and 
there  results  a  veritable  spontaneous  flight  of  ideas  through 
facilitation  of  association  of  ideas  and  loss  of  depth  and 
clearness  of  mental  images ;  so  that  external  similarities, 
especially  of  sound,  lead  to  rhyming.  Speech  becomes  so 
rapid  that  it  may  be  unintelligible.  In  the  midst  of  apparent 
incoherence,  the  patient  may  show  a  perfect  memory  in  the 
repetition  of  poetry  or  in  the  expression  of  details  of  the 
past.  Even  in  his  flight  of  ideas  it  may  be  possible  to  excite 
his  attention  and  obtain  relevant  answers  to  questions. 

The  delusions  of  mania  are  seldom  fixed,  and  they  are 
usually  expansive;  compared  with  the  grand  delusions  of 
paretic  dementia,  they  are  less  exaggerated  and  less  sense- 
less and  absurd. 


EMOTIONAL    EXALTATION.  129 

The  state  of  feeling  may  be  in  general  gay,  satisfied,  but 
it  is  rarely  constant  and  usually  passes  rapidly  from  one  to 
another  form.  The  emotional  state  is  often  easily  influenced 
(altered),  but  any  impression  made  is  transitory.  Impre- 
cations and  anger,  joy,  laughter,  weeping  and  wailing, 
shouting  and  whispering,  follow  one  another  without  order 
or  stability. 

The  motor  restlessness  and  sleeplessness  are  striking 
symptoms.  The  absence  of  sense  of  fatigue  and  the  quick- 
ness and  force  of  movements  seem  to  indicate  increase  of' 
muscular  power  (maniacs  are  popularly  thought  to  have 
superhuman  strength).  But  this  is  more  apparent  than 
real,  and  due  to  the  explosive  rather  than  sustained  char- 
acter of  muscular  action ;  and  with  the  continuance  of  motor 
excitement,  muscular  weakness  and  exhaustion  soon  super- 
vene. Experienced  persons,  as  a  rule,  can  easily  control 
physically  a  true  maniac,  and  only  two  good  attendants  are 
necessary,  even  in  the  wildest  excitement.  When  an  army 
of  attendants  is  necessary  to  overcome  a  maniac,  fear  and 
inexperience  are  the  cause,  or  the  maniac  is  an  epileptic  of 
vigor  or  one  in  the  very  early  stages  of  the  malady.  Any 
attempt  to  control  a  maniac  is  always  with  a  view  to  avoid 
injury  to  him ;  hence  the  need  sometimes  of  several  attend- 
ants. 

The  body-weight  falls  rapidly.  The  pulse  shows  no 
special  anomaly,  and  the  temperature  is  normal  unless  there 
be  a  physical  complication  of  some  kind. 

Etiology.  Mania  affects  both  sexes  with  about  equal 
frequency.  As  a  simple  psychosis  it  is  rare.  It  may  occur 
at  any  age,  but  it  is  most  frequent  in  the  earlier  years  of  ado- 
lescence.    Direct  and  definite  causes  cannot  always  be  de- 


130  OUTLINES  OF    PSYCHIATRY. 

termined.     It  sometimes  follows  head  injury.     Usually  the 
predisposition  to  insanity  is  marked. 

The  outbreak  of  simple  mania  is  rarely  sudden,  usually 
gradual  and  through  a  period  of  malaise  and  depression. 

The  course  is  one  with  remissions  and  exacerbations, 
lasting  from  a  few  months  to  a  year. 

Transitory  mania  of  a  few  hours'  or  days:  duration 
is  a  sure  sign  of  mental  instability  (degeneracy)  compar- 
able to  simple  emotional  depression;  or  it  is  a  transitory 
symptom  in  the  course  of  organic  disease  of  the  brain  (in- 
toxication, etc.)  and  has  the  significance  of  delirium.  A 
possible  relation  to  epilepsy  and  hysteria  should  never  be 
forgotten. 

The  terminations  oe  mania  are:  (1)  recovery 
(complete),  rare  except  in  periodic  and  recurrent  cases  dur- 
ing the  earlier  attacks;  (2)  recovery  with  defect,  which  is 
the  best  that  can  be  expected  after  a  prolonged  severe  attack, 
or  after  repeated  attacks;  (3)  secondary  dementia  of  a  quiet 
kind  and  secondary  dementia  with  continued  maniacal  symp- 
toms (chronic  mania)  ;  (4)  death  from  exhaustion,  inter- 
current disease,  or  accident  (physical  injury). 

Mania  gravis  (organic)  is  almost  always  fatal;  re- 
covery with  defect  is  possible. 

Diagnosis  of  the  maniacal  state  is  easy,  based  always 
on  the  presence  of  excitement — the  increased  flow  of  ideas, 
the  changeable  emotional  condition,  and  the  motor  restless- 
ness; but  it  is  difficult  to  make  an  immediate  diagnosis  of 
simple  mania. 

In  the  first  place,  organic  disease  must  be  excluded  by 
careful  examination  for  its  signs.  The  cerebro-spinal  fluid 
should  always  be  examined  in  case  of  doubt,  for  it  may  af- 
ford means  of  positive  diagnosis  of  an  oragnic  disease  which 


EMOTIONAL   EXALTATION.  131 

other  symptoms  do  not  justify.  With  regard  to  the  ques- 
tion of  its  degenerate  significance  only  the  history  and 
course  are  of  value  as  the  basis  for  a  conclusion. 

Mania  is  to  be  distinguished  from  the  common  maniacal 
symptoms  of  paretic  dementia  by  the  signs  of  that  disease — 
alterations  of  the  reflexes,  of  pupillary  reactions,  of  speech, 
and  of  the  cerebro-spinal  fluid ;  finally  by  the  dementia  that 
characterizes  diffuse  inflammatory  affections  of  the  cortex. 

Intoxications  (alcohol,  lead,  etc.)  are  to  be  diagnosticated, 
by  the  history  and  by  the  special  symptoms. 

Epilepsy  and  hysteria  as  a  basis  are  revealed  by  certain 
symptomatic  peculiarities  (see  Epileptic  and  Hysteric  In- 
sanity) and  the  history  and  course. 

Hallucinatory  delirium  is  distinguished  by  the  multitude 
of  hallucinations,  which  as  such  are  not  characteristic  of 
mania  (see  Hallucinatory  Insanity). 

From  these  considerations  it  is  clear  that  immediate 
diagnosis  of  the  significance  of  maniacal  symptoms  is  often 
impossible;  time  for  observation  is  almost  always  required. 

The  prognosis  of  mania  is  not  favorable  for  absolutely 
complete  recovery,  except  in  mild  acute  cases;  and  it  is  still 
more  uncertain  with  regard  to  recurrence. 

Treatment.  Mania  should  always  be  treated  in  an 
institution  for  the  insane.  On  the  part  of  the  general  prac- 
titioner certain  indications  require  immediate  attention,  for 
transfer  of  a  patient  to  a  hospital  is  often  possible  only 
after  a  few  days.  The  restlessness  and  sleeplessness  call 
for  hypnotics,  when  sufficient  nurses  have  been  provided 
to  guard  the  patient  from  self-injury  and  injury  to  others 
and  material  things.  Sulphonal,  trional,  and  chloral  hydrate 
are  most  useful ;  opiates  are  of  little  use.  Hyocine  hydro- 
bromate  overcomes  motor  restlessness,  and  it  is  convenient 


132  OUTLINES  OF    PSYCHIATRY. 

for    hypodermatic    administration;    however,    its    dangers 
should  never  be  forgotten. 

In  the  early  stages  of  home-care  mechanical  restraint 
may  be  absolutely  necessary,  but  this  should  be  applied  with 
discrimination  and  care  to  avoid  injury.  The  patient  should 
often  be  kept  in  bed,  and  for  restraint  the  bed  should  always 
be  chosen,  where  the  patient's  arms  and  legs  can  be  confined 
by  means  of  sheets,  which  may  be  so  employed  that  injury 
of  the  patient  is  impossible.  A  patient  restrained  should 
never  be  left  alone,  and  restraint  should  be  avoided  if  pos- 
sible, and  never  be  allowed  to  replace  personal  care. 

The  transfer  to  an  institution  is  not  always  easy ;  decep- 
tion of  the  patient  is  perfectly  justifiable  to  attain  the  end 
quietly;  but  the  deception  should,  if  practicable,  be  ex- 
plained to  the  patient,  with  its  reasons,  by  those  that  have 
practiced  it,  in  order  to  shield  the  asylum  authorities. 

In  an  institution  the  treatment  can  be  carried  out  sys- 
tematically. Hypnotics  used  judiciously  are  of  value;  pro- 
longed baths  are  often  useful;  care  for  food  and  drink  in 
generous  quantities  is  absolutely  necessary.  Isolation  in  the 
acute  stage  of  excitement  is  always  indicated.  A  patient 
should  not  be  left  alone  in  a  padded  cell,  but  humanely  re- 
strained in  bed  with  constant  watching.  Details  of  man- 
agement cannot  be  given,  but  patience  and  expectant  symp- 
tomatic treatment  are  the  general  requirements.  It  is  very 
harmful  and  dangerous  to  push  chemical  (drug)  restraint; 
mild  doses  of  hypnotics  are  alone  justifiable.  Time,  not 
medicine,  cures  mania,  if  it  is  to  be  cured.  Exercise  (forced 
walking)  in  the  active  stages  of  mania,  is  contra-indicated 
as  likely  to  help  to  exhaustion. 


LESSON  XVII. 

Hallucinatory  Insanity. 
(Delirium.) 

Hallucinatory  insanity,  or  delirium,  is  characterized  by 
hallucinations  and  defective  consciousness  of  self  and  time 
and  place  (clouding  of  consciousness).  It  is  a  simple  form 
of  insanity  if  not  a  complication  of  some  other  insanity,  func- 
tional or  organic.  It  is  distinguished  from  mania  and  mel- 
ancholia by  the  fact  that  the  emotional  accompaniment  is 
indistinct,  changeable,  or  wanting;  and  by  the  mental  con- 
fusion, which  occurs  in  the  course  of  mania  and  melancholia 
only  as  an  episode. 

Hallucinatory  insanity  presents  two  clinical  pictures,  an 
active  and  a  passive. 

Active  hallucinatory  insanity.  After  a  few  days 
of  premonitory  symptoms — headache,  anxiety,  restlessness, 
sleeplessness,  which  in  themselves  present  nothing  distinct- 
ive— the  patient  presents  the  distinguishing  mental  symp- 
toms. His  action,  speech,  and  facial  expression  show  that 
he  is  the  subject  of  numerous  hallucinations  of  changing 
character,  affecting  one  or  more  of  the  senses.  His  emo- 
tional expressions  are  extremely  varied  owing  to  variation 
of  the  character  of  the  hallucinations.  This  is  so  rapid  that 
there  is  both  ideational  and  emotional  confusion  (clouding 
of  consciousness,  loss  of  self-consciousness).     In  language 

183 


134  OUTLINES  OF   PSYCHIATRY. 

the  patient  is  incoherent,  either  momentarily  or  constantly. 
Self-consciousness  may  reappear  momentarily,  but  almost 
immediately  is  lost  in  the  whirl  of  confused  hallucinations. 
The  patient  at  the  height  of  the  disease  loses  his  individual- 
ity, recognizes  neither  friends  nor  surroundings,  and  knows 
not  even  to  respond  to  the  calls  of  nature.  Thus  joy,  sor- 
row, fear,  anger,  etc.,  may  occur  momentarily  and  lead  to 
corresponding  acts.  In  all  mental  and  motor  manifesta- 
tions, however,  the  characteristic  note  is  variation  without 
law  or  order.  If  there  be  delusions,  they  display  the  same 
changeable  character  and  lack  of  all  logical  system — delus- 
ional confusion.  Active  hallucinatory  insanity  is  often  mis- 
taken for  mania,  especially  since  it  may  simulate  very  closely 
the  furious  (delirious)  stage  of  mania.  Little  by  little, 
after  a  longer  or  shorter  period  of  great  excitement,  the 
patient  grows  quieter  and  the  hallucinations  fade.  With 
the  subsidence  of  active  symptoms  there  is  a  gradual  re- 
awakening of  self-consciousness.  Of  the  active  period  of 
the  disease,  memory  is  wanting  or  very  imperfect. 

Passive  hallucinatory  insanity  resembles  passive 
melancholia  and  acute  dementia.  The  patient  is  inactive, 
inclined  to  remain  in  bed,  or  may  wander  about  aimlessly. 
Silence  is  characteristic.  The  face  expresses  in  movements 
of  the  features  the  existence  of  pleasant,  disagreeable, 
or  fearful  ideas,  and  the  attitude  or  regard  may  show 
through  what  senses  the  patient  is  hallucinated.  The  hal- 
lucinations are  less  variable  than  in  the  active  form. 
There  is  evidence  of  the  same  confusion  of  mind  in  the 
absence  of  all  sense  of  self  and  surroundings  and  the  ab- 
sense  of  reaction  to  external  impressions.  This  condition 
may  pass  into  one  exactly  like  that  of  a  stuporous  melan- 


HALLUCINATORY    INSANITY.  135 

cholia,  from  which  it  can  be  distinguished  only  by  the  his- 
tory of  precedent  and  primary  hallucinations. 

These  two  clinical  pictures  may  alternate  in  a  given  case. 

Special  symptomatology.  The  predominance  of  hal- 
lucinations and  illusions  is  the  distinctive  characteristic;  all 
other  mental  symptoms  are  secondary  to  these.  The  chang- 
ing delusions  never  show  any  system,  except  in  the  second- 
ary chronic  stage  of  dementia,  when  they  may  assume  feeble 
logical  association.  The  emotional  state  corresponds  with 
the  hallucinations,  etc.,  and  shows  similar  variations. 
Owing  to  the  clouding  of  self-consciousness,  after  subsidence 
of  the  active  symptoms  memory  of  the  subjective  and  ob- 
jective experiences  of  the  height  of  the  disease  is  defective 
or  absolutely  wanting. 

Thl  physical  symptoms.  The  pulse  shows  nothing 
abnormal.  The  temperature  is  normal  in  the  absence  of  a 
complication.  Fever  points  to  a  physical  complication  or 
grave  delirium  or  exhaustion.  The  patient  loses  weight 
rapidly. 

Refusal  of  food  is  common,  for  the  patient  is  too  restless 
to  take  food  of  which  he  has  no  conscious  need ;  thus  forced 
feeding  is  often  required. 

Etiology.  The  causes  of  hallucinatory  insanity  are 
those  of  insanity  in  general — hereditary  predisposition  and 
exciting  accidental  causes.  It  is  a  very  frequent  form  of 
mental  disease;  many  cases  of  short  duration  never  reach 
an  institution  for  the  insane.  It  affects  males  more  fre- 
quently than  females,  and  occurs  most  frequently  in  middle 
life. 

The  direct  or  accidental  causes  are  infections  and  mental 
shock  following  physical  injuries,  surgical  operations,  etc. 
It  is  by  far  the  most  frequent  form  of  so-called  puerperal 


136  OUTLINES  OF   PSYCHIATRY. 

insanity,  it  follows  typhoid  fever  especially,  and  occurs  dur- 
ing the  course  of  pneumonia  as  a  complication. 

The  outbreak  of  the  symptoms  is  usually  more  or  less 
acute. 

The  duration  varies  from  a  few  days  to  a  few  months ; 
cases  of  a  year's  duration  have  ended  in  recovery. 

The  prognosis  is  relatively  favorable  for  all  cases  taken 
as  a  whole.  The  more  acute  the  symptoms  and  the  longer 
they  have  continued  the  more  unfavorable  the  prognosis. 
Recoveries  under  hospital  treatment  are  estimated  at  forty 
per  cent;  the  milder  cases  that  recover  at  home  raise  this 
percentage  decidedly. 

Terminations.  If  recovery  does  not  ensue,  it  may  end 
in  chronic  dementia  with  persistence  of  faded  hallucinations 
and  delusions,  which  may  develop  into  a  certain  feeble  sys- 
tematization  of  ideas;  or  in  simple  secondary  mental  en- 
feeblement  (dementia). 

Death  may  ensue  from  the  direct  cause  of  the  psychosis 
(puerperal  or  other  infection,  trauma,  etc.),  or  from  acci- 
dental complications.  The  psychosis  may  lead  directly 
to  general  physical  exhaustion  ending  in  death,  a  danger 
always  present  when  excitement  is  great  and  continued. 

The  diagnosis  depends  upon  the  demonstration  of  hal- 
lucinations and  the  clouding  of  self-consciousness  as  initial 
and  predominating  symptoms,  and  the  proof  that  they  are 
not  accidental  symptoms  of  organic  disease  of  the  nervous 
system. 

The  differential  diagnosis  is  not  always  easy  in  the 
beginning.  From  the  delirium  of  fever,  it  is  distinguished 
by  the  fever,  especially  if  the  delirium  subside  and  augment 
with  the  rise  and  fall  of  the  temperature ;  but  a  delirium  that 
persists  or  suddenly  begins  after  the  febrile  crisis  of  an  infec- 


HALLUCINATORY   INSANITY.  137 

tious  disease  should  give  rise  to  doubt  of  the  assumed  febrile 
nature  of  the  mental  disturbance. 

As  an  intercurrent  symptom  in  the  course  of  other  psy- 
choses (melancholia,  mania,  hysteria,  epilepsy,  periodic  in- 
sanity), only  the  history  and  observation  make  its  distinction 
possible. 

From  mania  it  is  distinguished  by  the  multitude  of  hal- 
lucinations and  disturbance  of  self-consciousness,  which  are 
never  observed  in  mania.  The  maniacal  patient's  attention 
can  be  attracted  and  directed  here  and  there ;  the  hallucinated 
patient  is  entirely  preoccupied  with  his  hallucinations,  and 
his  attention  can  be  attracted  rarely  if  at  all ;  besides,  the 
very  rapid  play  of  the  emotions  is  foreign  to  mania,  notwith- 
standing the  fact  that  the  maniacal  present  varied  emotions 
(laughing,  weeping).  The  maniac  shows  at  almost  all 
times  that  he  is  perfectly  aware  of  himself  and  his  surround- 
ings, and  his  excitement  but  rarely  attains  a  degree  of  in- 
tensity in  which  there  is  loss  of  orientation. 

The  active  form  of  hallucinatory  insanity  is  very  often 
called  mania;  but  careful  observation  and  weighing  of  symp- 
toms will  usually  make  the  distinction  possible;  in  a  few 
cases  where  a  differential  diagnosis  is  impossible,  the  solu- 
tion of  the  question  must  be  left  to  observation  in  hospital. 

From  the  passive  form  of  melancholia  it  may  be  impos- 
sible to  distinguish  immediately  the  passive  form  of  hallu- 
cinatory delirium.  The  points  of  differential  diagnosis  are 
the  variation  of  symptoms  in  hallucination  as  compared 
with  their  stability  in  melancholia,  and  signs  showing  that 
the  melancholiac  is  self-conscious. 

From  acute  dementia  passive  hallucinatory  insanity  is 
distinguished  by  the  facial  expression,  which  shows  reaction 
to  hallucinations,  but  which  is  empty  and  expressionless  in 


138  OUTLINES  OF   PSYCHIATRY. 

acute  dementia.  In  acute  dementia  the  patient  is  listless  and 
makes  no  spontaneous  effort  of  consequence,  and  no  resist- 
ence  to  others  that  attempt  to  move  him  or  lead  him  about ; 
the  hallucinated  patient  is  much  less  readily  directed  or 
moved  in  bed  or  elsewhere,  for  he  frequently  resists,  or 
attempts  to  avoid  the  approach  of  others. 

Mania  gravis  as  an  organic  cerebral  disease,  is  distin- 
guishable by  the  initial  and  continued  fever ;  the  very  stormy 
excitement ;  the  rapid  exhaustion ;  the  tremor  and  muscular 
spasms  and  paralyses;  and  other  signs  of  organic  disease  of 
the  brain.  It  should  be  remembered  that  a  grave  delirium 
may  terminate  a  case  of  initial  hallucinatory  insanity. 

The  furious  excitement  of  paretic  dementia  is  distin- 
guished from  simple  hallucinatory  insanity  by  the  presence 
of  signs  of  organic  cerebral  disease. 

Epileptic  hallucinatory  delirium  can  only  be  distin- 
guished by  means  of  the  history  and  observation.  The  same 
is  true  of  hysteric  delirium. 

Treatment.  In  the  presence  of  insanity  beginning  as 
delirium,  especially  if  a  probable  cause  in  infection  (fever, 
puerperal  state)  can  be  found,  if  possible  the  patient  should 
be  treated  at  home  or  in  a  general  hospital,  if  means  of 
isolation  and  intelligent  nursing  are  at  hand.  A  febrile  pa- 
tient should  not  be  moved  if  it  be  possible  to  avoid  it.  Pos- 
sible physical  complications  (pneumonia)  should  be  care- 
fully excluded.  Since  many  cases  are  of  short  duration  ter- 
minating in  recovery,  the  transfer  to  an  institution  for  the 
insane  should  be  made  only  when  other  means  of  proper 
care  are  wanting,  or  the  course  and  character  of  the  symp- 
toms indicate  a  more  or  less  prolonged  duration  of  the  dis- 
ease. 

There  are  several  indications — rest  and  quiet,  and  stim- 


HALLUCINATORY   INSANITY.  139 

ulating,  supporting  treatment,  with  protection  of  the  patient 
from  self-injury  and  prevention  of  injury  to  others. 

The  patient  should  be  kept  in  bed  in  an  isolated,  quiet 
room,  in  a  subdued  light,  and  cared  for  by  a  minimum  num- 
ber of  nurses,  all  other  persons  being  excluded.  The  nour- 
ishment should  be  fortifying  and  given  in  generous  quanti- 
ties— milk  and  eggs  will  often  be  most  suitable  and  most 
easily  administered  if  forced  feeding  be  required;  nutri- 
tive enemas  may  be  indicated.  Prepared  and  concen- 
trated foods  may  be  useful,  but  they  should  never  be  used 
exclusively  or  with  the  idea  that  in  small  amount  they  take 
the  place  of  more  bulky  food.  Stimulants — wine,  ale,  beer, 
etc., — may  be  useful;  brandy,  camphor,  etc.,  may  be  indi- 
cated in  certain  conditions  of  collapse  or  general  weakness. 
Lukewarm  packs  and  prolonged  baths  also  have  a  calming 
effect. 

The  use  of  hypnotics  should  be  very  cautious,  because 
to  obtain  their  effect  it  is  usually  necessary  to  employ  very 
large  doses.  Bromides  may  be  tried ;  chloral  hydrate,  sul- 
phonal,  and  trional  may  be  alternated ;  hydrobromate  of 
hyoscin  and  duboisin  may  be  used  hypodermatically,  but  al- 
ways with  care,  and  not  for  long  periods. 

The  patient  should  never  be  left  alone.  Mechanical  re- 
straint may  be  necessary,  but  in  all  cases  when  it  is  required 
it  should  never  be  an  excuse  for  neglect  of  constant  personal 
attention. 


LESSON  XVIII. 


Acute  Dementia. 
General  Remarks  on  the  Simple  Insanities. 


Acute  dementia  is  characterized  by  a  comparatively 
sudden  and  primary  arrest  of  all  the  mental  functions,  which 
may  be  partial  or  complete.  The  patient  resembles  in  his 
listless  vacuity  a  passive  idiot. 

The  primary  origin  of  the  dementia  is  its  distinguishing 
diagnostic  feature  in  contrast  with  dementia  secondary  to 
some  functional  or  organic  brain  disease. 

Acute  dementia  is  very  rare,  and  for  this  reason  the  diag- 
nosis of  it  should  be  made  with  great  care  and  always  after  a 
sufficient  period  of  observation. 

Clinically  the  picture  is  one  of  striking  mental  vacuity. 
If  the  patient  can  be  induced  to  speak,  which  is  rare,  he 
shows  his  emptiness  of  mind,  his  lack  of  ideas,  in  his  want 
of  knowledge  of  his  surroundings  and  feelings,  and  in  his 
inability  to  recognize  his  own  name.  The  facial  expression 
is  void;  the  features  are  relaxed;  saliva  runs  from  the 
mouth ;  urine  and  feces  are  passed  without  apparent  knowl- 
edge or  attention;  no  appetites  are  expressed,  and  the  pa- 
tient must  be  fed  like  an  infant. 

The  marks  that  distinguish  acute  dementia  from  passive 
melancholia  and  passive  hallucinatory  insanity,  are  its  pri- 
mary origin ;  the  passive  indifference  and  lack  of  resistance 

140 


ACUTE  DEMENTIA.  141 

to  others ;  the  empty  facial  expression ;  and  in  contrast  with 
melancholia  the  absence  of  memory  for  the  period  of  acute 
illness  after  recovery.  However,  it  is  not  always  possible 
to  make  a  differential  diagnosis.  There  are  cases  of  pas- 
sive melancholia  that  are  exact  pictures  of  acute  dementia, 
the  only  distinguishing  features  of  which  are  outbursts  of 
furious  violence  in  the  course  of  melancholia.  If  these  do 
not  occur  a  supposed  case  of  acute  dementia  may  finally 
prove  to  have  been  a  delusional  (passive)  melancholia. 

The  temperature  is  subnormal,  the  pulse  slow,  respira- 
tion superficial,  and  all  the  physical  functions  are  more  or 
less  reduced  in  activity. 

Terminations.  Recovery,  if  it  occur,  takes  place  grad- 
ually, with  improvement  in  the  physical  functions.  Re- 
covery may  be  complete  in  mild  cases  and  those  of  short  du- 
ration ;  or  incomplete  with  signs  of  permanent  mental  weak- 
ness. Death  may  result  from  exhaustion  or  arrest  of  general 
nutrition ;  or,  as  is  the  rule  in  fatal  cases,  from  some  physi- 
cal complication,  especially  tuberculosis. 

Etiology.  The  causes  of  acute  dementia  are  mainly 
mental  shock.  It  occurs  in  males  of  youthful  age  most 
frequently,  and  is  a  sign  of  defective  nervous  organization. 

Course.  The  disease  may  last  a  few  weeks  or  some 
months  and  finally  end  in  recovery, — the  usual  result.  An 
apparent  acute  dementia  ending  in  recovery  after  several 
vears,  is  a  case  of  delusional  melancholia. 

The  prognosis  of  acute  dementia  is  on  the  whole  favor- 
able. 

The  diagnosis  is  difficult,  for  it  simulates  many  other 
conditions. 

Hallucinatory  insanity  (passive)  is  to  be  distinguished 
from  it  by  the  facial  expression  and  other  signs  of  mental 


142  OUTLINES  OF   PSYCHIATRY. 

activity,  especially  the  more  or  less  marked  resistance  to 
efforts  made  to  move  or  care  for  the  patient,  as  compared 
with  the  indifference  and  absolute  passiveness  with  vacuity  of 
countenance  observed  in  acute  dementia. 

Passive  (stuporous)  melancholia  has  a  facial  expression 
of  sadness,  sorrow,  or  fear,  and  the  patient  resists  and  is 
difficult  to  care  for  and  feed  because  of  opposition.  There 
is  tonicity  or  hypertonicity  of  the  muscles;  in  acute  de- 
mentia the  muscles  are  relaxed. 

Temporary  mental  vacuity  occurs  in  the  course  of 
epilepsy.  Such  conditions  are  to  be  recognized  only  by  the 
history  and  observation  of  their  course. 

Organic  brain  disease  may  cause  dementia  (aphasic  con- 
ditions), but  attentive  examination  will  reveal  the  organic 
accompaniment  and  explain  the  nature  of  the  case. 

The  treatment  should  comprise  rest  in  bed,  stimulating 
baths  with  massage  to  keep  up  the  circulation,  rich  diet,  care 
for  cleanliness,  and  use  of  tonics — wine,  iron,  strychnine, 
quinine,  etc.  With  the  re-awakening  of  the  mind,  care 
should  be  exercised  to  avoid  shock  or  strain. 

The  patient  should  be  transferred  after  a  few  weeks  to 
an  institution  for  the  insane,  if  circumstances  have  not  made 
this  necessary  earlier. 

GENERAL  REMARKS   CONCERNING  THE   SIMPLE   FUNCTIONAL 

INSANITIES. 

The  four  forms  of  simple  insanity,  melancholia,  mania, 
hallucinatory  delirium,  and  acute  dementia,  with  their  vari- 
ous clinical  pictures,  it  will  be  noted,  cover  all  possible  vari- 
ations from  the  normal  mental  state,  except  that  of  primary 
delusional  insanity.  But  primary  delusional  insanity,  while 
pre-eminently  a  functional  psychosis,  is  practically  always 


ACUTE  DEMENTIA.  143 

degenerate,  and  therefore  it  finds  its  description  in  the  les- 
sons devoted  to  frankly  degenerate  forms  of  mental  alien- 
ation. As  simple  independent  forms  of  disease  they  exist, 
but  it  is  always  by  exclusion  that  they  are  diagnosticated, 
and  it  is  rarely  possible  to  make  a  diagnosis  of  the  form  of 
insanity  on  superficial  observation. 

Simply  to  diagnosticate  insanity  may  be  easy,  but  study 
of  the  origin  and  course  of  the  case  is  usually  necessary  be- 
fore a  positive  classing  of  the  case  can  be  made.  In  certain 
cases,  especially  those  presenting  passive  symptoms,  only  a 
probable  diagnosis  can  be  made.  Many  cases  of  insanity  can 
not  be  scientifically  classified  for  the  reason  that  our  knowl- 
edge of  mental  diseases  is  imperfect ;  and  therefore  any  sta- 
tistical classification  should  allozv  for  a  certain  proportion  of 
unclassified  cases. 

In  the  presence  of  a  person  presenting  mental  symptoms, 
the  first  point  to  establish  is  the  genuineness  of  the  symp- 
toms. This  may  be  very  easy  if  the  symptoms  correspond 
with  those  empirically  established ;  if  they  do  not,  then  the 
physician  should  be  on  his  guard  against  simulation,  espe- 
cially if  there  be  any  reason  for  simulation. 

Dissimulation  of  insanity  is  not  rare  in  paranoia ;  it  occurs 
occasionally  in  melancholia,  but  is  hardly  possible  in 
other  forms  of  the  simple  insanities.  The  depressed 
patient  dissimulates  his  depression,  delusions,  and  im- 
pulses with  a  view  to  disarm  his  attendants  and  regain 
liberty  of  action — usually  with  suicidal  intent.  This  should 
never  be  forgotten ;  thus  the  diagnosis  of  recovery  becomes 
very  important. 

If  a  diagnosis  of  insanity  has  been  made,  the  next  point 
to  establish  is  the  presence  or  absence  of  signs  of  organic 
disease  of  the  nervous  system.     In  their  absence  we  may 


144  OUTLINES  OF   PSYCHIATRY. 

conclude  that  the  insanity  is  a  functional  manifestation.  If 
the  clinical  picture  presented  correspond  with  one  of  the 
four  simple  forms,  the  indications  for  treatment  are  evi- 
dent. Later  the  course  of  the  disease  will  usually  permit 
its  positive  classification  as  simple  or  as  an  episode  in  the 
course  of  a  degenerate  form  of  insanity,  if  the  history  or 
special  symptoms  do  not  make  this  possible  at  once. 

It  should  be  emphasized  that  the  simple  functional  in- 
sanities are  in  some  degree  signs  of  defect  of  nervous  or- 
ganization ;  and  the  occurrence  of  a  mania  or  melancholia 
may  be  the  first  marked  sign  of  the  deficiency,  which  later 
shows  itself  in  other  ways — in  other  forms  of  mental  in- 
stability. The  attack  may  be  repeated ;  one  form  may  alter- 
nate with  another;  periodic  or  circular  insanity  may  de- 
velop; other  forms  of  chronic  delusional  mental  disease  may 
appear  later,  not  as  a  consequence  of  the  simple  insanity,  but 
as  an  additional  sign  of  the  fundamental  cerebral  defect. 

Recovery,  then,  in  cases  of  simple  functional  insanity, 
must  be  understood  as  meaning  disappearance  of  all  active 
symptoms  and  return  to  the  previous  state.  The  individual 
is  no  longer  insane,  but  in  the  vast  majority  of  cases  of  "re- 
covery" there  remain  slight  neuro-functional  indications  of 
the  defective  and  weakened  organization,  which  bespeak  the 
liability  to  succeeding  attacks. 

Recovery  with  marked  defect  is  very  common ;  active 
symptoms  disappear,  but  the  patient  never  becomes  him- 
self ;  he  is  at  a  lower  mental  level — not  insane,  but  less 
acute  mentally,  more  emotional,  wanting  in  self-control  and 
initiative  and  persistency,  and  less  equipped  for  work  and 
life  in  general. 

Certain  cases  of  functional  insanity  occur  but  once  in 
a  lifetime.     It  is  possible  to  predict  in  some  cases  that  in 


ACUTE  DEMENTIA.  145 

all  probability  the  attack  will  not  be  repeated.  Such  cases 
are  those  in  which  heredity  has  played  a  small  part  or  none 
at  all,  and  the  exciting  cause  has  been  intense  in  its  effect 
(intoxications,  infections).  The  less  demonstrable  a  ma- 
terial exciting  cause,  the  more  significant  of  defect  of  cere- 
bral organization  is  the  attack  of  simple  insanity.  Further- 
more, the  absence  of  heredity  and  the  influence  of  a  material 
exciting  cause,  render  the  prognosis  of  complete  recovery 
from  an  attack  of  simple  insanity  much  less  favorable.  Sim- 
ple insanities  on  an  hereditary  basis  are  very  favorable  for 
recovery  from  the  attack,  but  subsequent  immunity  from 
attacks  is  rare. 

Secondary  dementia  following  the  acute  attack  of  in- 
sanity is  very  common.  The  dementia  may  be  extreme; 
usually  it  is  partial.  The  active  acute  symptoms  subside  and 
leave  a  state  of  mental  weakness  which  renders  the  patient 
incapable  of  an  independent  existence;  he  must  be  cared  for 
and  directed  in  his  daily  life,  though  physically  well.  Such 
patients  undergo  a  kind  of  re-education  in  asylums  and  thus 
lead  lives  useful  in  some  degree,  and  to  some  extent  they 
may  enjoy  life. 

The  acute  symptoms  of  simple  insanity  (mania,  melan- 
cholia) may  persist  years,  with  some  reduction  of  intensity, 
and  the  cases  merit  then  the  term  chronic.  Chronic  melan- 
cholia may  end  in  recovery  even  after  years  of  depression, 
but  as  a  rule,  dementia  develops  with  the  persistence  of  the 
depression. 

In  all  cases  of  chronic  insanity  when  physical  symptoms 
have  disappeared,  the  treatment  is  quite  different  from  that 
indicated  in  acute  cases.  Life  out  of  doors,  occupation, 
amusement  and  distraction,  are  indicated.     By  these  means 


146  OUTLINES  OF   PSYCHIATRY. 

the  excited  may  be  calmed,  the  depressed  awakened,  and 
thus  such  patients  may  be  improved. 

In  the  course  of  insanity,  the  symptoms  present  many 
variations.  Periods  of  calm  or  improvement  may  alternate 
for  a  time  before  a  definite  final  condition  is  reached  in  re- 
covery or  dementia.  Chronic  dements  are  very  unstable 
mentally,  and  their  history  is  made  up  of  records  of  states 
of  calm  and  states  of  excitement  or  depression. 

Chronic  patients  that  live  comfortably  in  asylums  may 
seem  able  to  return  to  society ;  but  when  tried  they  are  found 
wanting  and  usually  are  readmitted  with  an  aggravation  of 
former  symptoms. 


LESSON  XIX. 

Degenerate  Insanities. 

The  simple  functional  insanities  are  often  signs  of  de- 
generacy, and  always  so  if  they  occur  repeatedly  in  the 
same  person.  A  recurrent,  periodic,  alternating  or  circular 
insanity  is  a  positive  indication  of  defect  of  cerebral  con- 
stitution, usually  innate  and  associated  with  a  history  of 
nervous  heredity. 

Circular  insanity  means  a  cycle  of  insane  symptoms. 
Cases  thus  designated  present  a  period  of  melancholia,  a 
period  of  mania,  one  of  melancholia,  one  of  mania,  etc.,  al- 
ternately. Between  these  phases  there  may  be  a  period  of 
calm,  but  this  period  always  presents  certain  signs  of  nervous 
and  mental  instability.  This  period  of  comparative  lucidity 
may  be  prolonged  and  simulate  recovery.  The  striking  char- 
acteristic of  circular  insanity  is  the  comparative  suddenness 
of  transition  from  one  phase  to  another :  the  patient  goes  to 
bed  depressed  and  wakes  up  maniacal,  or  vice  versa;  the 
transition  may,  however,  take  place  slowly.  Sudden  tran- 
sition from  any  insane  state  to  lucidity  suggests  a  circular  or 
periodic  insanity. 

The  symptoms  of  the  phases  of  circular  insanity  are  like 
those  of  the  simple  forms  of  functional  insanity,  presenting 
all  degrees  of  intensity.  However,  in  circular  insanity  the 
symptoms  of  the  insane  phases  may  be  very  mild  and  thus 

147 


148  OUTLINES  OF   PSYCHIATRY. 

escape  observation  for  some  time,  until  finally  they  become 
pronounced ;  and  as  a  rule,  the  symptoms  are  less  intense  than 
in  corresponding  forms  of  simple  insanity.  The  phases  may 
be  of  different  intensity  and  duration;  the  period  of  depres- 
sion may  be  marked  or  slight ;  and  this  is  true  of  the  mani- 
acal period.  Some  cases  of  so-called  periodic  insanity  are 
circular  in  the  sense  that  an  outbreak  of  more  or  less  pro- 
nounced mania  is  preceded  by  a  short  prodromal  stage  of 
depression.  The  physical  symptoms  of  the  phases  are  much 
the  same  as  those  that  occur  in  simple  mania  and  melan- 
cholia. In  circular  insanity  the  acute  symptoms  may  be  ex- 
actly alike  in  corresponding  phases,  but  usually  the  repe- 
tition of  symptoms  is  not  identical. 

Etiology.  Circular  insanity  usually  occurs  before  the 
age  of  thirty,  and  most  frequently  in  the  female  sex. 
Hereditary  predisposition  is  found  in  a  large  percentage  ot 
the  cases.    It  is  not  a  frequent  form  of  mental  disease. 

Prognosis.  It  is  practically  an  incurable  form  of  in- 
sanity. A  lucid  interval  may  be  indefinitely  prolonged  and 
pass  for  recovery.  It  results  in  secondary  dementia  only 
after  years;  some  cases  never  show  signs  of  dementia.  If 
the  lucid  phase  be  wanting,  dementia  is  more  likely  to  super- 
vene, with  the  final  development  of  a  prolonged  or  chronic 
maniacal  state. 

Diagnosis.  It  is  necessary  to  distinguish  circular  in- 
sanity from  organic  brain  disease  presenting  the  semblance 
of  a  cycle  of  mental  symptoms.  The  premonitory  depres- 
sion of  mania  should  not  lead  to  a  diagnosis  of  circular  in- 
sanity, nor  should  the  periods  of  calm  and  mental  exhaus- 
tion in  the  course  of  mania  with  subsequent  recrudescence 
of  symptoms  lead  to  such  a  diagnosis.  Certain  periodic 
mental  symptoms  of  epilepsy  might  lead  to  error  if  a  his- 


DEGENERATE  INSANITIES.  149 

tory  or  observation  of  other  signs  of  that  neurosis  were 
wanting.  From  simple  melancholia  and  mania  the  distinc- 
tion is  to  be  made  by  observation  and  the  history. 

Treatment  of  the  attack  does  not  differ  from  that  of 
simple  forms  of  functional  insanity.  In  the  interval  bro- 
mides may  be  given  to  advantage. 

Primary  delusional  insanity  is  a  degenerate  mental 
disease. 

Paranoia  is  a  term  that  is  applied  to  the  various  forms 
of  insanity  characterized  by  primary  distortion  of  the  in- 
tellect, to  which  any  accompanying  emotional  symptoms  are 
secondary.  In  the  simple  insanities  (melancholia  and 
mania)  the  emotional  disturbance  is  primary,  and  the  intel- 
lectual disturbance  is  a  consequence  or  simultaneous  ac- 
companiment of  this ;  in  paranoia,  distortion  of  the  intellect 
is  primary,  engendering  emotional  disturbance  secondarily. 

In  the  descriptions  of  the  types  of  paranoia  slight  modi- 
fications of  this  principle  will  be  seen,  but  the  preponderat- 
ing influence  of  the  intellectual  element  will  be  always  ap- 
parent. 

There  are  a  great  many  cases  of  psychic  degeneracy  re- 
vealed in  certain  intellectual  symptoms  which  may  never 
reach  the  degree  of  actual  insanity,  but  as  signs  of  de- 
generacy they  are  very  significant  and  closely  related  to 
paranoia.  For  this  reason  they  may  be  classed  as  rudimen- 
tary paranoia.  The  clinical  picture  is  that  of  imperative 
ideas. 

An  imperative  idea  is  one  that  assumes  more  or  less 
complete  control  of  the  mind,  thus  disturbing  or  inhibiting 
the  natural  play  of  association  of  ideas,  causing  distress  or 
annoyance  to  the  individual,  who  is  conscious  of  the  anomaly 
and  seeks  to  overcome  or  banish  it,  perhaps  with  some  tern- 


150  OUTLINES  OF   PSYCHIATRY. 

porary  success ;  but  the  idea  returns  again  and  again,  until 
finally  it  controls  the  thought  and  action  of  the  patient.  This 
anomaly  may  consist  of  one  idea  or  several  related  ideas. 
It  is  the  insistence  of  idea  or  ideas  rather  than  the  nature  of 
the  thought,  that  distinguishes  the  phenomenon.  Psycho- 
logically we  may  say  that  an  imperative  idea  arises  as  a  re- 
sult of  limitation  of  association  of  ideas,  but  this  does  not 
explain  the  abnormality.  It  is  best  simply  to  examine  the 
symptom  objectively. 

The  symptom  may  occur  only  under  certain  circum- 
stances, or  exist  constantly  without  any  reference  to  exter- 
nal surroundings.  Some  patients  are  forced  to  think  in 
numbers,  to  occupy  themselves  with  mathematical  problems : 
one  counts  his  steps  or  the  number  of  houses,  or  is  constantly 
trying  to  multiply,  divide,  or  extract  the  square  root  of  num- 
bers, etc.  Other  examples  are  afforded  by  persons  that  are 
constantly  a  prey  to  some  peculiar  idea.  One  is  forced  to 
think  of  or  seek  the  cause  of  things,  why  the  world  exists,  "of 
what  use  is  it  ?"  why  do  things  grow  ?  why  do  people  do  this 
or  that?  Another  is  forced  to  think  of  obscene  things,  to 
repeat  in  thought  foul  words  or  to  imagine  the  nudity  or 
appearance  of  parts  of  the  body  of  others ;  another,  in  think- 
ing of  sacred  things,  immediately  is  forced  to  think  of  pro- 
fanity and  sin  (by  contrast)  ;  or  the  beautiful  suggests  the 
ugly  and  repugnant. 

A  common  form  of  imperative  idea  is  the  so-called  in- 
sanity of  doubt  :  the  patient  suddenly  attempts  to  review 
his  acts,  and  frightened,  cannot  assure  himself  that  he  did 
this  or  that  correctly :  "Did  I  put  the  right  address  on  the 
letter?  Did  I  put  it  in  the  letter-box?  Was  the  cheque 
signed?  Did  I  take  the  right  medicine?  Were  my  words 
and  manner  proper  under  the  circumstances?"     Some  pa- 


DEGENERATE  INSANITIES.  151 

tients  possessed  by  obscene  or  disgusting  ideas,  fear  they 
have  spoken  them  or  written  them,  and  thus  brought  shame 
and  disgrace  on  themselves;  the  fear  is  that  this  was  done 
unconsciously ;  they  have  no  memory  of  having  done  it,  but 
no  positive  memory  of  not  having  done  it;  for  they  cannot 
recall  their  acts  in  detail,  and  the  fear  paralyzes  thought. 
Such  patients  put  a  constant  watch  on  themselves,  retire 
from  society,  and  avoid  writing  materials.  Some  patients 
are  constantly  thinking  "What  if?" 

Others  have  an  impulse  to  avoid  all  possible  sources  of 
contamination  by  disease,  and  from  fear  resort  to  most 
minute  care  to  avoid  dirt  and  objects  touched  by  others 
(mysophobia),  using  the  minutest  care  in  washing  them- 
selves uselessly  and  repeatedly. 

Some  have  fear  of  open  places  devoid  of  people  (agora- 
phobia) ;  others  are  oppressed  in  closed  rooms  and  crowds 
(claustrophobia),  immediately  imagining  the  accidents 
that  might  supervene  under  the  circumstances,  and  are  par- 
alyzed in  expectancy  of  disaster. 

All  such  patients  have  a  certain  amount  of  self-control, 
except  at  times,  with  complete  consciousness  of  the  anomaly. 
This  leads  frequently  to  the  fear  of  insanity,  for  which  they 
often  seek  advice.  This  fear  may  become  a  conviction  and 
lead  to  suicidal  despair. 

The  imperative  ideas  may  engender  imperative  acts  of 
an  impulsive  kind — utterance  of  obscene  or  profane  words, 
etc.  Such  impulsive  acts  are  very  rarely  of  a  violent  kind 
that  endangers  the  life  of  others.  If  such  acts  occur,  the 
patient  is  more  than  ever  impelled  to  retire  from  contact  with 
others,  and  is  thus  forced  to  abandon  all  his  usual  activities ; 
he  goes  to  bed  and  becomes  impossibly  slow  in  everything 
he  does. 


152  OUTLINES  OF   PSYCHIATRY. 

We  observe  analogies  of  the  imperative  idea  normally, 
in  acts  done  out  of  habit  or  superstition — such  as  always  tak- 
ing the  same  streets,  the  same  side  of  the  street,  entering  a 
building  at  the  same  door,  etc. — usually  with  an  ill-defined 
thought  that  to  do  otherwise  might  bring  bad  luck.  The  per- 
sistence of  a  tune  or  a  certain  phrase  in  thought  suffices  to  il- 
lustrate the  nature  of  the  pathologic  phenomenon. 

The  ETioeogy  of  imperative  ideas  lies  in  a  defective 
nervous  constitution,  usually  shown  by  other  neuropsychic 
symptoms,  and  very  frequently  engrafted  on  an  hereditary 
taint. 

It  is  also  to  be  remarked  that  many  subjects  of  impera- 
tive ideas  are  naturally  painfully  conscientious,  and  the 
malady  may  begin  in  this  conscientiousness  at  a  very  early 
age.  It  is  a  disease  of  youth  and  early  adult  life.  It  may 
arise  spontaneously,  or  as  the  result  of  some  exciting 
cause — acute  weakening  physical  illness  or  some  mental  or 
moral  shock.  It  develops  gradually,  and  for  a  long  time 
may  be  known  only  to  the  patient,  who  through  shame  and 
fear  conceals  his  thoughts;  if  it  seem  to  have  a  sudden  be- 
ginning, probably  the  initial  symptoms  have  escaped  obser- 
vation and  elude  investigation. 

The  prognosis  is  unfavorable.  If" bodily  disease  has 
contributed  to  cause  the  development  of  the  symptoms, 
restoration  to  physical  health  may  be  followed  by  disappear- 
ance of  the  insistent  ideas.  Usually  the  symptoms  are 
chronic,  showing  variation  of  intensity.  A  case  may  develop 
into  typical  paranoia.  The  only  danger  to  life  lies  in  the  pos- 
sibility of  suicide. 

The  diagnosis  depends  upon  the  peculiar  idea  or  ideas, 
the  effect  on  the  conduct  of  the  patient,  the  primary  origin, 
and  the  co-existence  of  consciousness  of  the  abnormal  char- 


DEGENERATE  INSANITIES.  153 

acter  of  the  symptoms.  It  is  possible  to  confound  some  of 
these  forms  of  rudimentary  paranoia  with  melancholia, 
mania,  etc.,  if  these,  as  they  may,  present  imperative  ideas ; 
however,  attention  to  the  history  and  the  interrelation  of 
symptoms  will  usually  make  the  nature  of  the  case  clear. 
The  same  is  true  of  imperative  ideas  of  hysteric  or  epilep- 
tic origin.  Delusions  and  hallucinations  make  no  part  of  the 
insanity  of  imperative  idea ;  when  these  exist  we  have  to  do 
with  some  other  form  of  insanity,  of  which  the  imperative 
idea  is  a  symptom  or  which  has  been  developed  out  of  the 
imperative  idea. 

Treatment  of  these  cases  of  insanity  of  imperative  idea 
falls  usually  to  the  general  practitioner,  for  whom,  if  he 
have  not  great  patience  and  tact,  they  become  annoying,  ex- 
asperating patients,  insistently  demanding  care  and  advice, 
arguing  interminably,  constantly  redemanding  reassurance 
that  rarely  reassures  more  than  a  moment,  an  hour,  or  a  day. 

The  medical  treatment  should  be  symptomatic  and  al- 
ways have  in  view  the  establishment  of  robust  physical 
health.  Sometimes  minute  directions  for  carrying  out  medi- 
cal treatment  have  a  good  temporary  effect,  if  the  patient  is 
assured  that  the  anomaly  rests  upon  a  physical  basis  for 
which  the  treatment  is  required. 

Morally  it  is  the  duty  of  the  physician  to  assure  and 
reassure  the  patient  that  he  is  in  no  danger  of  becoming  in- 
sane. In  some  cases  change  of  scene,  travel,  exercise,  amuse- 
ment, etc.,  have  a  calming  effect.  Hydrotherapy,  electricity, 
or  other  means  of  treatment  that  exercise  a  suggestive  in- 
fluence, may  be  tried.  In  some  cases  the  patient  should  be 
encouraged  to  continue  his  occupation  and  renew  his  ef- 
forts to  convince  himself  that  his  fears  are  unfounded.  If 
excitement  or  great  depression  supervene,  the  patient  must 


154  OUTLINES  OF   PSYCHIATRY. 

be  treated  as  for  mania  or  melancholia,  forestalling  always 
some  possible  act  of  despair. 

The  physician  should  not  grow  impatient  or  tire,  within 
reason,  of  demonstrating  in  conversation  the  false  position 
of  the  patient.  He  should  win  the  patient's  confidence  by 
a  consistent  course,  and  he  can  thus  often  bring  comfort, 
even  though  it  be  beyond  his  power  to  give  permanent  relief. 

Agoraphobia,  claustophobia,  and  fear  of  high  places 
may  have  an  exciting  physical  cause  in  disease  of  the  ear — 
external,  middle  or  internal.  Babinski  has  demonstrated 
the  relations  of  ear-disease  to  disturbances  of  normal  gal- 
vanic vertigo,  and  shown  that  removal  of  a  small  quantity 
of  cerebro-spinal  fluid  by  lumbar  puncture  may  influence 
favorably  or  cure  aural  vertigo  and  tinnitus.  In  cases  of 
agoraphobia,  etc.,  the  possible  aural  origin  calls  for  exami- 
nation of  the  state  of  galvanic  vertigo,  and  the  possibility  of 
a  favorable  result  from  lumbar  puncture  would  justify  the 
operation  in  case  an  anomaly  of  galvanic  vertigo  is  found. 


LESSON  XX. 
Paranoia. 

Paranoia  is  a  form  of  insanity  characterized  by  delu- 
sions of  primary  and  spontaneous  origin,  which  become  logic- 
ally systematized  and  exercise  a  predominating  influence  on 
the  thought,  feeling,  and  action  of  the  individual.  It  is 
chronic  in  its  course,  though  presenting  exacerbations  and 
remissions,  and  accompaniments  of  secondary  emotional  an- 
omalies as  reactions  to  the  delusions,  which  produce  at  times 
the  features  of  acute  insanity. 

Paranoia  is  essentially  a  degenerate  insanity,  though  in 
some  cases  it  begins  late  and  the  outbreak  follows  some  ex- 
citing cause. 

An  hereditary  predisposition  is  almost  always  demon- 
strable, but  this  is  not  absolutely  essential.  Following  acute 
insanity,  a  secondary  systematized  delusional  insanity  may 
develop  resembling  in  many  immediate  mental  symptoms  a 
primary  paranoia.  If  the  immediate  symptoms  are  those 
of  paranoia,  and  they  have  arisen  secondarily,  it  is  the  his- 
tory and  the  course  that  distinguish  it  from  the  primary 
form  of  the  disease.  For  this  reason  it  is  vain  to  deny  that 
paranoia  may  arise  in  an  individual  presenting  no  other  sign 
of  original  psycho-physical  degeneracy  than  the  insane 
symptoms.  It  is  only  logical  to  recognize  that  injurious  in- 
fluences affecting  an  organism  originally  normal,  may  pro- 

155 


156  OUTLINES  OF   PSYCHIATRY. 

duce  symptoms  exactly  like  those  arising  as  a  result  of  a 
congenitally  defective  neuro-cerebral  constitution.  In  other 
words,  paranoia  may  develop  in  any  originally  well-consti- 
tuted individual  as  a  result  of  causes  that  have  altered  the 
neuro-cerebral  state  to  a  profound  degree.  Thus  alcoholism 
may  produce  a  paranoia  indistinguishable  from  that  of  origi- 
nal degeneracy.  Since  neuro-psychic  degeneracy  of  descend- 
ants may  be  the  result  of  alcoholism  in  ancestry  (parents),  it 
is  logical  to  assume  that  degeneracy,  if  inherited,  must  first 
have  been  acquired  (accidentally)  by  progenitors. 

Paranoia  is  essentially  a  functional  mental  disease,  with- 
out known  organic  basis. 

The  important  fact  objectively  in  relation  to  paranoia, 
original,  late,  acquired,  or  secondary,  is  that  it  is  an  incur- 
able disease.  Recovery  has  never  yet  been  reported  by  a 
competent  observer. 

Paranoia — rudimentary,  in  course  of  development,  and 
complete — is  a  very  common  form  of  mental  disease.  It 
makes  up  a  large  percentage  of  inmates  of  asylums,  and  is 
extremely  common  in  society.  As  a  rule  the  persons  known 
as  "cranks"  are  candidates  for  paranoia  or  actual  paranoiacs. 

Original  paranoia  is  a  designation  for  those  cases  of 
primary  delusional  insanity  in  which  the  symptoms  can  be 
traced  back  to  years  of  childhood,  to  the  beginning  of  men- 
tal development.  The  psychosis  here  appears  as  the  result 
of  development  of  a  character  abnormal  ab  ovo.  Usually 
heredity  is  very  marked — the  family  is  degenerate. 

The  early  symptoms  consist  of  peculiarities  of  charac- 
ter :  the  child  is  quiet,  retiring,  dreamy,  imaginative,  differ- 
ent from  other  children;  less  amenable  to  the  influence  of 
others;  less  affectionate  and  more  exacting;  perhaps  ill- 
humored,   quarrelsome,   cruel,   or  violent,   and  always  ex- 


PARANOIA.  157 

tremely  selfish  and  suspicious.  History  of  convulsions, 
night-terrors,  early  hallucinations,  persistent  onanism,  and 
other  nervous  symptoms,  is  frequent.  The  physical  con- 
dition often  shows  defects  of  development  and  numerous 
signs  of  degeneracy. 

The  striking  symptoms  of  insanity  appear  at  the  period 
of  puberty.  Even  before  this,  such  candidates  may  have 
shown  weakness  or  one-sided  development  of  mind  and  have 
been  impossible  in  school  because  of  their  suspicions  and 
their  ideas  of  persecution. 

The  delusions  develop  gradually;  usually  they  are  ideas 
of  persecution,  accompanied  later  by  melancholic,  maniacal, 
hypochondriac,  or  stuporous  symptoms,  these  secondary 
emotional  states  being  very  changeable.  Sometimes  the 
primary  delusions  are  those  of  grandeur  and  personal  im- 
portance. Owing  to  the  early  origin  of  the  psychosis  and 
the  frequency  of  intercurrent  states  of  emotional  disturb- 
ance cases  of  original  paranoia  pass  quite  rapidly  to  more  or 
less  marked  dementia. 

Doubtless  many  cases  of  the  insanity  of  puberty,  ordi- 
narily regarded  as  acute  functional  insanities,  are  cases  of 
paranoia  that  are  temporarily  concealed  by  some  form  of 
episodical  emotional  disturbance. 

Grand  delusions  are  the  immediate  precursors  of  de- 
mentia. Original  delusions  of  persecution  that  do  not 
change  to  delusions  of  grandeur,  permit  a  prognosis  of  con- 
tinuance at  a  certain  level  of  intelligence  for  several  years, 
perhaps  many.  However,  dementia  usually  shows  itself 
early  in  cases  of  original  paranoia. 

Late  paranoia.  This  variety  of  paranoia  makes  its 
appearance  after  puberty,  often  as  late  as  the  fifth  decade 
of  life.     It  begins  in  delusions  of  persecution.    As  in  origi- 


15S  OUTLINES  OF    PSYCHIATRY. 

nal  paranoia,  there  is  often  a  history  of  hereditary  predispo- 
sition, and  almost  always  a  history  of  peculiarities  of  char- 
acter; of  eccentric  habits  of  action  and  thought,  or  an  ex- 
aggerated belief  in  the  efficacy  or  utility  and  possibility  of 
certain  social  reforms,  which  engender  conviction  and  un- 
limited faith  in  ideas  and  means  which  logic  vainly  shows  to 
be  of  relative  rather  than  of  absolute  value.  Candidates  for 
paranoia  and  paranoiacs  in  history  have  been  founders  of 
religious  sects,  initiators  of  reform  movements  (temper- 
ance, social  systems,  anarchy).  The  paranoiac's  ideal  is  for 
him  reality;  opposition  to  his  scheme  is  the  signal  for  the 
use  of  force  that  in  his  opinion  must  prevail. 

The  specious  resemblance  of  insane  religious  and  re- 
formatory delusions  and  prevalent  religious  and  moral  ideas, 
accounts  for  the  fact  that  many  religious  and  reformatory 
paranoiacs  are  tolerated  in  society,  notwithstanding  the  dis- 
turbance they  cause.  It  is  remarkable  that  many  forms  of 
religion  owe  some  of  their  principles,  some  of  their  rites,  to 
insanity  of  a  delusional  type.  The  creation  of  new  religious 
sects  under  our  own  eyes  is  most  illuminating  for  an  under- 
standing of  the  prehistoric  origin  of  religions  consecrated  in 
human  faith  by  the  immeasurable  lapse  of  time. 

The  pathologic  mental  symptoms  gradually  grow  more 
distinct  and  at  last  are  emphasized  by  striking  changes  of 
conduct.  The  patient  becomes  unusually  preoccupied  with 
self,  abandons  his  ordinary  social  habits,  and  is  retiring  and 
uncommunicative.  His  acts  become  peculiar;  he  does  and 
says  things  that  seem  to  have  no  rational  motive;  he  is  un- 
usually obstinate  and  irritable.  At  this  period  he  may  con- 
tinue to  follow  his  occupation.  There  are  no  extraordinary 
physical  symptoms  though  the  patient  may  be  sleepless  and 
devoid  of  appetite. 


PARANOIA.  159 

An  attitude  of  suspicion  is  usually  remarked.  Sooner  or 
later,  with  or  without  external  cause,  the  patient  reveals  his 
state  of  mind  in  some  strikingly  insane  act  or  in  the  expres- 
sion of  insane  delusions. 

The  initial  delusions  of  persecution  sooner  or  later  may 
lead  to  the  development  of  grand  delusions,  and  the  two  may 
continue  to  exist  side  by  side  indefinitely ;  or  the  original  de- 
lusions of  persecution  may  disappear  almost  completely  with 
the  appearance  of  grand  delusions,  in  which  the  patient  con- 
tinues to  live  with  demented  satisfaction. 

It  is  sometimes  possible  to  trace  psychologically  the  logic 
of  the  transformation—  -the  origin  of  the  grand  delusions  in 
those  of  persecution.  The  paranoiac  reasons  often  as  fol- 
lows :  "I  know  I  am  persecuted,  and  I  remember  that  all 
my  life  there  have  been  events,  slights,  little  annoyances, 
which  at  the  time  I  could  not  explain  and  which  I  passed 
over,  but  which  are  now  as  clear  as  day :  they  were  timid, 
initial  efforts  of  my  persecutors,  who  have  grown  courage- 
ous in  the  belief  that  they  can  persecute  me  with  impunity  to 
themselves,  and  accomplish  my  destruction.  I  have  never 
done  anything  to  merit  this  persecution.  Why  then  have  I 
enemies  who,  unseen,  make  my  life  unbearable?  There  must 
be  a  reason ;  I  must  be  an  obstacle  in  the  way  of  my  enemies. 
They  would  not  risk  their  lives  to  kill  me  unless  there  were 
some  great  advantage  for  them  in  my  disappearance  from 
society  and  the  earth."  Thus  searching  a  reason,  he  finally 
convinces  himself  that  he  is  of  great  importance  for  the 
world,  and  that  his  life  means  much  for  society,  but  that  he 
is  a  menace  to  a  few  (his  persecutors). 

The  final  grand  delusions  developed  on  this  soil  depend 
for  their  content  on  the  education,  social  standing,  and  the 
society  in  which  the  patient  lives.   One  is  persecuted  by  com- 


160  *  OUTLINES  OF    PSYCHIATRY. 

petitors,  because  he  has  discovered  some  great  invention  that 
will  revolutionize  society ;  another,  because  he  is  destined  to 
save  the  world,  is  persecuted  by  the  wicked,  by  Satan,  by  all 
the  powers  of  evil,  by  Free  Masons  and  other  secret  societies. 
Another  is  the  object  of  machinations  because  he  is  the  heir 
to  a  great  fortune  or  a  throne  which  others  possess  and  fear 
to  lose;  another,  because  he  has  been  secretly  appointed  to 
some  high  office  by  the  ruler  of  his  country  or  by  the  Pope. 
Another,  because  he  is  secretly  loved  by  a  prominent  heiress 
or  princess,  is  persecuted  by  aspirants  to  her  hand ;  another 
is  persecuted  because  his  enemies  desire  to  alienate  his  wife's 
affections  (jealousy). 

The  transformation  cannot  always  be  traced  thus.  It 
sometimes  takes  place  suddenly,  as  if  it  were  the  result  of  a 
dream  or  an  hallucination  which  immediately  and  spon- 
taneously reveals  to  the  patient  his  personal  importance. 
Legends,  novels,  and  dreams  often  afford  the  material  for 
the  development  of  the  secondary  grand  delusion. 

Hallucinations  of  one  or  more  of  the  senses  are  very 
common  symptoms  in  the  course  of  paranoia,  and  they  may 
be  the  basis  of  the  delusions  or  the  influence  that  gives  a 
particular  coloring  to  the  clinical  picture.  In  some  cases  the 
persecution  consists  of  hallucinations  of  bodily  sensations  at- 
tributed to  magnetism,  electricity,  poisons,  gases,  telegra- 
phy, etc.  Hallucinations  of  hearing  reveal  the  voices,  the 
designs  of  the  enemies ;  or  the  patient's  thoughts  are  stolen 
from  him,  for  he  hears  them  immediately  repeated ;  or  there 
is  a  concealed  telephone  that  reacts  to  his  ideas  and  feelings 
and  reveals  in  language  his  thoughts  to  others,  etc. 

Illusions  of  hearing  are  also  common  (the  clock  talks). 
Illusions  of  sight  are  more  common  than  visual  hallucina- 
tions:   the  patient   sees  himself  watched   by  others;   those 


PARANOIA.  161 

around  him  are  his  enemies  in  disguise;  he  recognizes  for- 
mer slight  acquaintances  in  strangers;  he  sees  by  the  man- 
ner of  his  friends  that  they  are  innocently  made  to  do  the 
bidding  of  his  enemies,  or  that  they  are  influenced  and  perse- 
cuted by  his  enemies  because  they  are  his  friends.  Halluci- 
nations may  become  so  numerous  and  intense  that  the  case 
presents  the  picture  of  hallucinatory  delirium. 

The  attitude  of  the  paranoiac  toward  society  is  of  the 
greatest  importance — the  effect  of  the  delusions  and  halluci- 
nations on  the  conduct  of  the  patient. 

For  a  time  the  persecuted  paranoiac  may  accept  his  per- 
secution with  a  certain  resignation  manifest  in  a  state  of 
depression ;  he  may  be  silent,  suspicious,  uncommunicative, 
or  even  in  despair ;  or  he  seeks  to  avoid  society  and  sur- 
rounds himself  with  real  or  imaginary  means  (charms,  etc.) 
to  protect  himself  from  his  enemies.  Perhaps  he  appeals 
for  help  to  his  friends  or  the  authorities,  who  in  their  power- 
lessness  to  bring  comfort  may  soon  be  confounded  with  his 
unseen  enemies. 

Almost  inevitably,  however,  the  continuance  of  persecu- 
tion causes  sooner  or  later  the  assumption  of  an  attitude  of 
aggressive  self-defense  or  retaliation,  and  the  patient  is  then 
extremely  dangerous  to  others — to  friends  and  strangers 
alike ;  for  it  may  be  accident  alone  that  determines  the  person 
or  persons  that  come  to  be  regarded  as  hostile  to  him ;  and 
with  his  life  threatened,  he  feels  justified  in  resorting  to  mur- 
der, which  is  sometimes  carried  out  with  fury  and  horrifying 
cruelty,  but  more  frequently  with  great  cunning  and  careful 
premeditation  and  coolness. 

The  irritability  of  the  persecuted  may  cause  outbursts 
of  great  violence  toward  persons  having  no  direct  relation  to 


162  OUTLINES  OF   PSYCHIATRY. 

their  insane  ideas.  A  sudden  hallucination  or  illusion  may- 
cause  an  attack  on  a  perfect  stranger. 

With  grand  delusions  the  danger  of  violence  diminishes, 
but  it  is  still  possible  if  persecutory  delusions  co-exist,  or  re- 
appear and  take  the  upper  hand,  as  they  may  episodically. 
When  grand  delusions  take  absolute  control  and  bring  de- 
mented satisfaction  to  the  patient,  if  the  persecution  is  re- 
membered, it  is  made  light  of,  and  enemies  that  can  do  no 
harm  to  so  powerful  a  person  are  magnanimously  pitied  and 
forgiven. 

The  delusions  may  be  very  limited  in  number  and  com- 
paratively fixed;  hence  the  old  misnomer,  monomania — in- 
sanity on  one  subject.  Usually  there  is  variation  and 
growth  of  delusional  ideas  through  spontaneous  intellectual 
activity,  which  takes  place  logically  but  is  based  upon  false 
premises  (delusions).  Thus  in  paranoia  there  is  always 
a  systematization  of  ideas  which  transforms  the  character 
of  the  patient  and  makes  him  another  individual.  The  para- 
noiac lives  in  himself  and  for  himself,  no  matter  how  philan- 
thropic he  may  seem ;  he  is  an  example  of  absolute  egotism, 
in  which  all  former  sympathies,  inclinations,  and  affections 
are  modified  and  ultimately  lost. 

The  intellectual  powers — intelligence,  memory,  acquired 
knowledge,  reasoning  powers — may  remain  intact  for  years, 
perhaps  until  death,  always  subordinated,  however,  to  the 
uses  of  the  "evolved  system  of  delusions." 

Dementia  of  a  certain  degree  supervenes  in  the  course  of 
time;  it  is  common  and  marked  in  original  paranoia  and  it 
may  be  developed  by  an  outburst  of  acute  insanity  in  the 
course  of  paranoia ;  it  is  slight  or  unnoticeable  in  late  para- 
noia, especially  in  certain  varieties  of  it  later  described. 

The  dissimulation  of  delusions  by  paranoiacs   is  very 


PARANOIA.  163 

common  because  of  their  intact  powers  of  observation  and 
reasoning.  This  is  most  prone  to  occur  at  the  period  when 
the  persecuted  individual  has  changed  to  a  persecutor.  He 
has  been  called  insane, 'confined  perhaps  in  an  asylum;  he 
has  recognized  the  fact  that  his  delusions  and  conduct  are 
the  cause  of  his  restraint,  and  he  has  enough  self-control  to 
dissimulate  his  delusions  and  conform  in  his  expression  of 
ideas  and  in  his  conduct  to  what,  by  observation,  he  has 
learned  his  physicians  regard  as  normal ;  and  if  he  can  per- 
sist long  enough  he  believes  he  can  gain  his  liberty  and  be 
free  to  act  in  harmony  with  his  delusions.  Usually  the  mo- 
tive of  dissimulation  is  vengeance.  Dissimulation,  of  short 
duration,  of  more  immediate  designs  of  vengeance  against 
those  around  the  patient  is  common,  and  one  of  the  most 
frequent  causes  of  homicide  in  asylums.  Thus  paranoiacs, 
in  general,  are  to  be  classed  among  the  most  dangerous  in- 
sane patients. 

The  danger  of  suicide  in  paranoia  is  not  great,  though  a 
paranoiac  may  kill  himself  in  despair  at  persecution  or  in  a 
temporary  state  of  depression. 

It  is  evident  that  the  diagnosis  of  paranoia  may  be  dif- 
ficult, and  require  lengthy  observation;  that  any  paranoiac 
may  be  very  dangerous  in  society  during  the  predominance 
of  persecutory  delusions;  that  the  discharge  of  a  paranoiac 
from  restraint  in  a  period  of  apparent  remission  entails  a 
very  grave  responsibility;  that  his  care  in  an  asylum  should 
be  most  painstaking  in  order  to  prevent  injury  to  others. 


LESSON  XXI. 

Paranoia. 
(Continued.) 

Clinically  several  varieties  of  paranoia  within  the  two 
groups  are  observed,  distinguished  by  the  presence  of  cer- 
tain predominating  mental  symptoms. 

1.  Hypochondriac  paranoia  is  so-called  from  the 
predominance  of  hypochondriac  delusions  and  hallucinations 
concerning  the  body  and  the  various  organs,  which  are  at- 
tributed to  the  malevolence  of  enemies  that  use  secret,  in- 
visible means  to  induce  the  unpleasant  symptoms :  poison, 
electricity,  magnetism,  dust,  gases,  etc. 

2.  Neurasthenic  paranoia,  a  variety  of  hypochon- 
driac, is  dependent  upon  neurasthenic  symptoms — fatigue, 
headache,  disorder  of  digestion,  etc.,  which  are  interpreted 
as  due  to  the  influence  of  enemies. 

3.  Hysteric  paranoia  is  the  paranoiac  state  of  mind 
engrafted  on  the  hysteric  neurosis.  The  delusions  are  usu- 
ally religious  or  erotic,  and  the  cases  may  be  thus  placed  in 
one  or  another  of  the  following  groups. 

4.  Hallucinatory  paranoia  is  characterized  by  the 
number  and  predominance  of  hallucinations  in  the  clinical 
picture.  Hypochondriac  paranoia  is  thus  a  variety  of  this 
form. 

5.  In  erotic  paranoia  the  delusions  concern  sexuality, 

164 


PARANOIA.  165 

sexual  relations,  sexual  things;  often  the  delusions  are  ob- 
scene or  disgusting  in  character  or  relation ;  sometimes  they 
are  idealizations  of  love  and  repugnant  only  by  their  silliness. 
Delusions  of  jealousy,  of  infidelity,  etc.,  are  frequent.  Erotic 
paranoia  often  leads  to  importunity  of  some  prominent  per- 
son by  the  amorous  patient. 

6.  In  religious  paranoia  the  delusions  are  religious 
or  have  some  relation  to  religion,  and  are  very  frequently 
tinged  with  eroticism.  One  patient  finds  a  mission  in  the 
Bible;  another  has  had  a  miraculous  conception  and  is  about 
to  give  birth  to  a  second  Savior  of  the  world;  another  sees 
in  persecution  the  work  of  the  devil,  witches,  etc.  (demono- 
mania). 

7.  Reformatory  paranoia.  Insane  reformers  of  all 
classes  are  represented  in  this  variety — temperance  advo- 
cates, religious  reformers  and  founders  of  sects,  anarchists, 
and  assassins  of  kings,  rulers,  presidents  and  other  promi- 
nent persons. 

8.  Querulous  paranoia  (quarrelsome  paranoia). 
These  insane  persecutors  become  such  as  a  result  of  their 
original  suspicious  nature ;  they  see  their  rights  infringed  on 
all  sides,  especially  by  their  neighbors,  and  they  resort  to  the 
law  for  redress  for  the  most  futile,  insignificant  causes,  or 
as  the  result  of  some  lost  lawsuit.  When  this  condition  is 
fully  developed,  the  patient  is  constantly  engaged  in  quar- 
rels and  lawsuits,  and  he  may  pursue  this  comminatory 
course  for  years  without  having  his  true  condition  recog- 
nized. The  loss  of  his  suit  only  stimulates  him  to  begin  new 
suits ;  to  bring  actions  against  the  authorities,  or  to  malign 
and  persecute  them  in  letters  to  the  press,  in  spoken  insults, 
or  even  by  personal  violence.  The  true  condition  once 
recognized  and  the  patient  declared  insane,   in  an  asylum 


166  OUTLINES  OF    PSYCHIATRY. 

he  becomes  a  most  disturbing  element  and  often  succeeds  in 
obtaining  his  liberty  and  bringing  unsuccessful  suit  for  dam- 
age against  the  authorities.  They  are  frequently  their  own 
lawyers  and  show  a  surprising  acquaintance  with  legal  tech- 
nicalities and  procedure. 

In  asylums  such  patients  interest  visitors  in  their  welfare 
and  thus  often  bring  about  the  intervention  of  the  authorities 
for  their  release.  The  clear  intelligence,  logic,  and  acuteness 
of  these  patients  in  defending  their  position  and  describing 
the  wrongs  to  which  they  have  been  subjected,  deceive  the 
unskilled  observer  and  even  physicians ;  and  they  often  place 
alienists  in  an  embarrassing  position.  These  patients  rarely 
exhibit  hallucinations,  and  dementia  not  at  all  or  at  a  very 
late  period,  and  their  delusions  are  so  far  within  the  range 
of  possibility  that  they  long  go  unrecognized  as  pathologic. 
Success  in  obtaining  release  from  confinement  causes  re- 
newed excesses  in  combativeness  and  acts  of  violence,  which 
usually  cause  their  return  to  the  asylum,  where  several 
repetitions  of  the  experience  prove  sufficient  to  prevent  their 
release. 

Special  symptoms  op  paranoia.  Hallucinations  of 
hearing  are  the  most  frequent.  Occasionally  auditory  hal- 
lucinations are  unilateral.  The  phenomenon  of  hearing  one's 
own  thoughts  has  already  been  mentioned.  The  "voices" 
are  often  located  in  one  or  another  part  of  the  body  and  may 
lead  to  doubling  of  the  personality — the  patient  believes  his 
body  is  occupied  by  one  or  more  persons  that  think  and  speak 
to  him  or  through  him.  Hallucinations  of  taste  and  smell 
are  frequent,  and  often  associated  with  erotic  ideas  and  de- 
lusions of  poison.  The  hallucinations  of  general  sensibility 
are  characteristic  of  hypohcondriac  paranoia.  They  may 
be  so  intense  as  to  render  the  patient  stupid  and  catatonic : 


PARANOIA.  167 

he  thinks  he  is  deprived  of  arms  and  legs;  that  his  bowels 
have  "rotted  out" ;  that  he  has  turned  to  glass,  etc. 

The;  speech  and  writing  of  the  paranoiac  often  show 
striking  peculiarities.  Certain  words  are  created  that  have 
a  significance  only  for  him;  in  his  writing  he  employs  cer- 
tain signs  and  symbols  that  have  for  him  some  mystic  or 
delusional  meaning. 

The  conduct  of  the  paranoiac  may  be  entirely  guided 
by  his  delusions  or  hallucinations ;  or  it  may  present  nothing 
strikingly  abnormal,  and  the  true  state  of  mind  be  revealed 
in  writings  or  when  conversation  is  directed  to  some  special 
subject,  or  when  for  some  reason  the  patient  is  made  indig- 
nant or  angry. 

Obstinate  refusal  of  food  sometimes  occurs,  usually  due 
to  fear  of  poison,  and  it  may  make  forced  feeding  necessary, 
as  in  simple  insanity. 

Physical  symptoms  make  no  part  of  paranoia,  aside  from 
those  that  occur  in  association  with  acute  intercurrent  men- 
tal symptoms  (excitement,  depression,  delirium). 

The  course  of  the  disease  has  already  been  sketched. 
It  should  be  added  that  the  course  is  sometimes  interrupted 
by  a  remission,  but  always  sooner  or  later  the  delusions  re- 
appear, and  they  are  the  same  or  an  evolution  of  those  en- 
tertained before  the  remission.  To  the  symptoms  of  para- 
noia acute  symptoms  of  insanity  may  be  added  and  tem- 
porarily dominate  the  clinical  picture.  It  is  possible  for  a 
paranoiac  to  have  and  recover  from  an  attack  of  acute  in- 
sanity (melancholia,  delirium). 

The  diagnosis  of  paranoia  is  sometimes  very  readily 
made;  often  it  is  a  very  delicate  matter,  requiring  long  ex- 
perience in  observation  of  the  insane  as  well  as  prolonged 
observation  of  the  given  case  under  favorable  circumstances. 


168  OUTLINES  OF   PSYCHIATRY. 

The  diagnosis  rests  on  the  presence  of  delusions  that  are 
primary  and  logically  systematized,  which  can  be  shown  to 
be  the  essential  element  of  the  case  around  which  all  other 
mental  symptoms  are  grouped. 

It  must  be  differentiated  from  melancholia.  The  delus- 
ions of  persecution  in  melancholia  are  a  secondary  result  of 
the  emotional  depression,  and  they  disappear  with  the  disap- 
pearance of  depression.  The  depression  of  paranoia  is  due 
to  the  delusions  and  continues  with  them,  to  disappear  only 
when  there  has  been  some  alteration  of  the  delusions ;  some 
evolution  of  them  in  the  sense  of  the  transformation ;  or  some 
hallucinatory  revelation  that  excites  an  alteration  of  the 
emotional  state.  An  essential  mark  of  distinction  between 
paranoia  (depressive)  and  melancholia,  is  the  personal  at- 
titude of  the  patient  toward  delusional  persecution :  the  para- 
noiac cannot  understand  his  persecution,  or  regards  it  as  un- 
merited suffering  for  which  he  is  nowise  morally  responsi- 
ble; the  melancholiac  knows  only  too  well  the  cause  of  his 
persecution — it  is  the  full  expression  of  divine  justice  meted 
out  to  him,  a  sinner,  etc.  This  difference  serves  also  to  dis- 
tinguish hypochondriac  melancholia  from  hyponchondriac 
paranoia. 

The  episodic  excitement  of  paranoia  is  to  be  differenti- 
ated from  mania  by  observation  of  the  delusions,  which  are 
temporary  and  unsystematized  in  mania. 

Hallucinatory  delirium  can  be  distinguished  from  epi- 
sodic delirium  in  the  course  of  paranoia  only  by  the  history 
and  observation  of  the  course  of  the  case. 

From  organic  insanity,  the  differentiation  is  to  be  made 
by  the  absence  of  all  signs  and  symptoms  of  intoxication  and 
organic  diseases  of  the  nervous  system.  It  should  be  remem- 
bered, however,  that  a  paranoiac  may  develop  organic  cere- 


PARANOIA.  169 

bral  disease;  that  chronic  alcoholism  is  capable  of  exciting 
paranoia.  Commonly,  however,  the  insane  state  due  to 
chronic  alcoholism  presents  certain  distinctive  features  that 
are  characteristic. 

Treatment.  From  the  foregoing  description  it  is  plain 
that  the  treatment  of  paranoia  must  be  essentially  sympto- 
matic, and  consist  in  the  main  of  intelligent  management  of 
the  patient.  Some  paranoiacs  never  require  commitment  to 
an  asylum ;  they  go  through  life  mildly  persecuted,  only  at- 
tracting attention  by  their  peculiarities.  Others,  in  the 
state  of  intense  persecution,  seek  protection  of  the  authori- 
ties, and  once  in  an  asylum  may  find  comfort  in  the  sense  of 
protection  felt  there.  Such  patients  once  discharged  some- 
times return  to  the  asylum  voluntarily  and  there  remain  by 
choice.  But  the  paranoiac  that  changes  to  a  persecutor  or 
avenger  absolutely  requires  confinement  in  an  asylum.  Hal- 
lucinatory paranoia  and  all  acute  episodes  of  the  disease  de- 
mand the  care  of  an  institution  for  the  insane.  The  discip- 
line and  means  for  regulating  employment  of  an  asylum 
often  have  a  happy  effect  in  modifying  the  conduct  of  such 
patients,  and  thus  they  come  to  be  in  a  way  useful  and  at 
the  same  time  they  have  comparative  comfort.  In  contrast 
with  "comfortable"  cases,  there  are  others  that  remain  dan- 
gerous, intractable,  and  impossible,  requiring  the  most  care- 
ful watching  at  all  times. 

The  discharge  from  an  asylum  of  a  patient  that  has  pre- 
sented frank  symptoms  of  paranoia  entails  a  grave  responsi- 
bility, and  it  should  never  be  approved  unless  it  has  been  ab- 
solutely demonstrated  that  the  patient  is  in  a  true  remission 
or  in  a  mental  state  devoid  of  danger  to  himself  and  others. 
The  physicians  that  may  be  called  upon  by  friends  or  by  the 
courts  to  aid  in  the  decision  of  this  question,  should  realize 


170  OUTLINES  OF   PSYCHIATRY. 

the  gravity  of  their  responsibility  and  refuse  to  act,  unless 
they  have  had  experience  in  the  care  and  observation  of  the 
insane.  Medical  observers  in  an  asylum  have  the  best  means 
of  knowing  a  patient  confined  there,  and  unless  a  want  of 
good  faith  can  be  clearly  demonstrated,  others  should  be 
guided  by  their  views.  There  is  not  a  superintendent  of  a 
public  institution  for  the  insane  who  will  not  gladly  submit 
any  case  to  the  judgment  of  others;  if  the  law  assumes  the 
responsibility  of  discharge,  the  physician  has  fulfilled  his 
function  if  he  has  expressed  his  opinion  of  the  case. 

Moral  insanity  deserves  mention  here  for  the  reason 
that,  like  original  paranoia,  it  is  a  manifestation  of  an  origi- 
nally defective  cerebral  organization,  and  may  exist  in  asso- 
ciation with  powers  of  intelligence  practically  intact.  The  de- 
fective mentality,  in  contrast  with  paranoia,  shows  itself  in 
deficiency  or  absence  of  moral  ideas  and  feelings  as  a  guide 
for  conduct.  Often  such  defective  persons  show  signs  of 
general  mental  weakness  (imbecility)  ;  but  in  some  cases  de- 
serving the  name  of  moral  insanity,  this  is  very  slight  or  un- 
noticeable,  while  the  moral  defect  is  profound.  The  peculi- 
arity may  be  traced  to  the  early  years  of  mental  develop- 
ment, and  frequently  there  is  a  marked  hereditary  taint,  ce- 
rebral or  nervous,  or  a  history  of  alcoholism  in  the  parents. 
Signs  of  physical  degeneracy  are  very  common.  The  moral 
imbecile,  as  a  child,  is  wanting  in  parental  affection,  willful, 
disobedient,  and  intractable,  cruel  to  sisters  and  brothers, 
and  to  all  animals.  If  he  can  be  kept  in  school,  he  makes 
himself  conspicuous  by  his  disobedience,  his  malicious  con- 
duct toward  his  associates,  and  his  want  of  all  sense  of 
shame  at  disgrace  or  punishment.  He  destroys  the  prop- 
erty of  his  fellow  pupils  for  the  pleasure  of  teasing  and  an- 
noying them,  and  to  enjoy  their  sorrow ;  he  bullies  the  feeble 


PARANOIA.  171 

and  respects  the  strong  from  fear.  He  is  incapable  of  a  feel- 
ing- of  sympathy,  and  lies  and  steals  merely  for  pleasure  or 
for  the  delight  felt  in  harming  others. 

With  puberty,  masturbation  and  other  sexual  excesses 
begin.  He  deserts  his  home  (sometimes  a  refined  one)  to 
consort  with  vagabonds  and  criminals.  He  begins  by  steal- 
ing at  home,  forging  cheques,  etc.,  to  the  detriment  of  his 
parents,  appealing  for  forgiveness,  perhaps  with  a  view  to 
gain  another  opportunity  to  satisfy  his  instincts.  If  such 
a  person  restrain  himself  temporarily  from  crime,  it  is  only 
from  the  motive  of  expediency.  Sooner  or  later  such  imbe- 
ciles fall  into  the  hands  of  the  law,  and  undergo  punishment ; 
sometimes  their  true  condition  is  recognized  and  they  find  a 
place  in  an  asylum. 


LESSON  XXII. 
Epileptic  Insanity. 

The  epileptic  is  prone  to  become  insane.  Only  a  small 
proportion  of  chronic  epileptics  go  through  life  without 
manifesting  some  form  of  mental  disturbance,  and  a  large 
proportion  become  chronic  dements. 

The  insanity  op  Epilepsy  is  very  important  because  it 
is  frequently  of  only  short  duration  and  often  leads  to  acts  of 
personal  violence  of  the  most  horrible  kind.  Insane  epilep- 
tics belong  to  the  most  dangerous  class  of  the  insane.  Their 
acts  of  violence  often  raise  the  question  of  legal  responsi- 
bility, because  of  the  seeming  premeditation  and  perfect 
consciousness  with  which  such  acts  are  at  times  committed. 

The  classic  attack  of  epilepsy  is  attended  by  disturbance 
or  loss  of  consciousness,  and  in  certain  cases  the  attack  con- 
sists only  of  momentary  loss  or  disturbance  of  consciousness. 
This  interruption  of  consciousness  may  precede,  follow, 
or  take  the  place  of  a  classic  convulsion,  and  be  so  prolonged 
as  to  constitute  a  mental  state — a  psychosis.  This  phenome- 
non is  therefore  named  in  relation  to  the  epileptic  attack,  pre- 
epileptic, or  post-epileptic,  insanity,  as  the  case  may  be;  when 
it  takes  the  place  of  an  attack,  it  is  called  the  epileptic  mental 
equivalent. 

PrE-EpieEptic  insanity  presents  itself  as  a  state  of 
clouded  consciousness  with  loss  of  self-consciousness  or  in- 

172 


EPILEPTIC  INSANITY.  173 

terruption  of  the  continuity  of  self-consciousness,  in  which 
the  patient  may  perform  the  most  complicated  acts  and  pre- 
sent the  outward  appearance  of  consciousness.  With  the  re- 
storation of  normal  consciousness,  memory  of  the  events  of 
the  period  is  wholly  wanting  or  very  imperfect.  This  state 
may  be  marked  by  hallucinations  and  delusions,  and  the  pa- 
tient may  be  depressed  or  exalted.  Often  the  patient  presents 
a  dream-like  state;  and  sometimes  with  hallucinations  and 
delusions  there  are  ideas  arising  from  former  experiences 
which  lead  to  acts  of  a  violent  kind.  Thus,  an  epileptic  may 
have  had  cause  to  feel  resentment  toward  some  one,  and  in 
a  state  of  clouded  consciousness  this  feeling  takes  control 
and  leads  to  an  act  of  vengeance,  carried  out  with  seeming- 
cunning  and  revolting  cruelty;  but  with  the  return  of  nor- 
mal consciousness  there  is  complete  amnesia  of  the  act. 

Pre-epileptic  insanity  frequently  ends  with  a  classic  at- 
tack of  epilepsy  or  a  series  of  attacks.  It  may  be  supposed 
that  the  attack  effaces  the  memory  of  the  events  of  the 
period  of  altered  consciousness,  just  as  the  hysteric  attack  is 
in  some  cases  the  dividing  line  between  the  two  separate 
states  of  consciousness  (double  personality). 

Post-epileptic  insanity,  which  follows  a  fit  or  a  series 
of  them,  does  not  differ  in  any  important  particular  from  pre- 
epileptic insanity,  but  it  is  a  more  frequent  phenomenon.  It 
usually  takes  the  form  of  hallucinatory  delirium,  in  which 
visual  hallucinations  of  fire  are  remarkably  frequent; but  hal- 
lucinations may  occur  in  all  the  senses.  Mania,  melancholia, 
and  delusional  clinical  pictures  occur,  and  a  state  of  cerebral 
exhaustion  may  simulate  acute  dementia.  The  duration 
varies  from  hours  or  days  to  months,  and  the  attacks  are 
frequently  repeated  at  longer  or  shorter  intervals,  present- 
ing frequently  great  uniformity  of  mental  symptoms. 


174  OUTLINES  OF   PSYCHIATRY. 

The  mentae  equivalent  of  the  epileptic  attack  does 
not  differ  from  pre-  and  post-epileptic  mental  disturbance  ex- 
cept in  that  it  arises  and  disappears  without  any  relation  to 
convulsions;  the  patient  remains  free  from  attacks  during 
the  continuance  of  the  psychosis. 

A  peculiar  mental  equivalent  is  exemplified  by  cases  of 
epileptic  ''fugue."  In  the  altered  state  of  self-consciousness 
the  patient  wanders  from  home,  and  on  coming  to  himself 
is  entirely  lost,  and  some  time  and  trouble  are  necessary  to 
establish  his  identity  and  regain  his  home.  Such  fugues 
may  very  rarely  have  several  months'  duration. 

Some  of  the  symptoms  of  epileptic  insanity  present  pe- 
culiar features  that  are  of  aid  in  making  a  diagnosis.  The 
hallucinations  are  usually  of  a  frightful,  horrible  nature, 
leading  to  great  intensity  of  reaction  in  fear  and  self-de- 
fense. In  contrast  with  these,  and  connected  with  an  ab- 
normal intensification  of  religiosity,  so  common  in  epilep- 
tics, the  hallucinations  may  concern  divine  things — God, 
angels,  saints,  the  devil,  etc.  The  delusions  are  varied,  but 
religious  delusions  are  common,  often  mingled  with  erotic 
ideas.  The  acts  of  insane  epileptics,  owing  to  their  auto- 
matic (reflex)  nature,  are  remarkable  for  their  suddenness 
and  violence;  and  such  patients  are  extremely  dangerous 
because  their  acts  are  usually  directed  with  a  view  to  do 
harm  and  are  carried  out  with  blind  fury.  The  disturbance 
of  self -consciousness  is  always  profound ;  often  there  is  com- 
plete or  temporary  loss  of  consciousness,  entailing  complete 
or  partial  amnesia.  Formerly  it  was  taught  that  complete 
amnesia  was  the  characteristic  mark  of  epileptic  uncon- 
sciousness, but  this  is  an  error;  imperfect  memory  for  the 
events  of  the  period  of  the  continuance  of  the  psychosis, 
does  not  exclude  epilepsy  as  a  cause.   The  epileptic  psychoses 


EPILEPTIC  INSANITY.  175 

are  remarkable  for  their  sudden  origin  and  their  sudden  dis- 
appearance. 

Chronic  epileptic  insanity  is  a  state  of  dementia 
arising  in  cases  of  long  continued  epilepsy,  or  in  some  cases 
rapidly  as  a  result  of  frequent  convulsions  at  a  comparatively 
early  age,  or  again  as  a  consequence  of  repeated  attacks  of 
acute  epileptic  insanity.  Epileptic  dementia  may  reach  a  pro- 
found degree,  the  patient  being  as  helpless  as  an  idiot. 
Usually  the  dementia  is  milder  and  shown  in  slowness  and 
dullness  of  intellect,  weak  memory,  great  irritability  and 
quarrelsomeness  often  expressed  in  violence,  with  a  certain 
selfishness  of  thought  and  action  that  makes  the  sufferer 
overconceited  and  sensitive.  The  majority  of  epileptic  de- 
ments, in  their  moments  of  calmness,  are  remarkable  for 
their  piety  and  gentleness,  which  a  real  or  imagined  slight 
may  instantly  change  to  the  most  furious  rage  with  mur- 
derous assault. 

As  episodic  and  intercurrent  clinical  pictures,  almost  any 
of  the  acute  insanities  may  appear  at  any  time  in  the  long 
and  hopeless  course  of  epileptic  dementia. 
^  ,^        Etiology.    \yA/e  do  not  know  why  epilepsy  causes  in- 
sanity, though  we  niay_ justly  conclude,  that  the  nervous  in- 
1  stability  (cortical)  that  presumably  lies  at  the  basis  of  epi- 
lepsy operates  similarly  to  unsettle     all  cortical  functions. 
Excesses  of  all  kinds,  especially  in  alcohol,  are  very  efficient 
exciting  or  aggravating  causes. 

Course.  The  acute  epileptic  insanities  frequently  end 
in  recovery,  but  there  is  almost  a  certainty  of  recurrence  and 
ultimate  development  of  epileptic  dementia.  The  single  at- 
tacks may  be  short  or  prolonged.  Epileptic  dementia  is  in- 
curable, and  renders  the  prognosis  of  the  epilepsy  itself  hope- 
less. 


176  OUTLINES  OF   PSYCHIATRY. 

Epilepsy  has  no  definite  pathology,  and  the  same  is  true 
of  epileptic  insanity,  though  in  chronic  epileptic  dementia 
certain  organic  cerebral  changes  are  always  found  which 
may  as  well  be  the  result  as  the  cause :  dural  adhesions,  milky 
arachnoid,  cerebral  atrophy,  minute  cortical  changes,  alter- 
ations of  the  diploe,  etc. 

The  diagnosis  of  epileptic  insanity  is  to  be  made  on  the 
basis  of  the  diagnosis  of  the  fundamental  neurosis.  The 
history  of  convulsions  and  epileptoid  disturbances  with 
manifestation  of  mental  symptoms  peculiar  to  epileptic  in- 
sane states,  makes  the  epileptic  nature  of  the  mental  trouble 
probable.  The  probable  diagnosis  is  still  further  strength- 
ened if  there  be  scars  on  the  tongue  and  about  the  face,  said 
to  result  from  falling  in  fits..  Observation  of  a  convulsion 
is  the  actual  demonstration  of  the  nature  of  the  disease. 

In  the  absence  of  a  history,  a  probable  diagnosis  may  be 
made  from  scars,  and  especially  from  the  nature  of  the  men- 
tal symptoms. 

Insanity  with  epilepsy  may  be  confounded  with  hysteric 
convulsions  with  mental  symptoms.  The  points  of  dif- 
ferential diagnosis  are  found  in  the  details  of  the  history 
or  in  observation  of  the  convulsions.  (See  Hysteric  In- 
sanity.) 

Acute  alcoholic  insanity  presents  some  close  analogies 
with  the  acute  mental  symptoms  of  epileptic  insanity.  ( See 
Alcoholic  Insanity.)  In  the  absence  of  a  history  of  epilepsy 
and  given  a  history  of  alcoholism  with  its  physical  signs, 
there  can  be  little  doubt ;  but  with  no  history  of  the  case,  and 
with  immediate  signs  of  alcoholism  there  is  reason  for  re- 
serve, for  epileptics  are  often  alcoholic ;  again,  a  few  chronic 
alcoholics  become  temporarily  epileptic  (alcoholic  epilepsy), 
and  in  such  a  case  even  the  fit  observed  is  not  absolutely  in- 


EPILEPTIC  INSANITY.  177 

dicative  of  chronic  epilepsy.  Observation  of  the  patient  in 
the  doubtful  case  is  the  only  means  of  making  the  diagnosis 
certain. 

Careful  clinical  examination,  even  if  a  history  be  want- 
ing, should  remove  any  doubt  that  might  arise  in  a  case  of 
mental  disturbance  and  convulsions  due  to  uremic  poison- 
ing, remembering  that  albumen  may  be  present  in  the  urine 
of  epileptics  at  times,  and  that  thorough  examination  of 
the  microscopic  and  chemical  elements  of  the  urine  would 
be  necessary  in  a  doubtful  case. 

Epileptic  insanity  may  be  confounded  with  organic  dis- 
ease of  the  brain  with  convulsive  symptoms,  especially  if  the 
previous  history  be  defective  or  wanting;  but  a  general 
neurologic  examination  will  usually  settle  the  question  be- 
yond doubt.  The  symptoms  that  may  possibly  occur  in  epi- 
lepsy and  suggest  organic  disease  of  the  nervous  system 
must  be  remembered.  After  a  convulsion  the  deep  reflexes 
may  be  absent  for  a  time ;  the  pupils  may  be  wide  and  react 
sluggishly  to  light  if  the  patient  be  under  the  Influence  of 
bromides;  in  chronic  epileptic  dementia  anomalies  of  the 
deep  reflexes  and  the  movements  of  the  pupils  occur  as  a  re- 
sult of  secondary  organic  disease  of  the  brain. 

The  differential  diagnosis  has  also  to  deal  with  brain 
tumors,  focal  cerebral  disease,  disseminated  (multiple)  scle- 
rosis, and,  most  important  of  all,  paretic  dementia  (paresis), 
in  all  of  which  convulsions  occur,  and  sometimes  apparently 
as  isolated  symptoms. 

Focal  cerebral  disease  is  revealed  by  permanent  disturb- 
ances of  the  deep  reflexes  and  paralyses  more  or  less  pro- 
nounced. 

Multiple  cerebro-spinal  sclerosis  is  to  be  diagnosticated 
by  several  more  or  less  pathognomonic  symptoms  or  signs : 


178  OUTLINES   OF   PSYCHIATRY. 

partial    paralyses,  exaggerated    reflexes,  scanning    speech, 
tremor,  cerebellar  gait,  partial  optic  nerve  atrophy,  etc. 

Paretic  dementia  may  early  present  epileptoid  and  para- 
lytic seizures  (attacks)  much  resembling  a  frank  epileptic 
fit.  The  differential  diagnosis  must  rest  on  the  presence 
of  positive  signs  of  the  organic  cerebral  disease :  pathologic 
alterations  of  the  deep  reflexes;  anomalies  of  the  pupils; 
tremor  of  lips  and  tongue ;  characteristic  speech ;  dementia ; 
leucocytosis  of  the  cerebro-spinal  fluid. 

Treatment  of  epileptic  insanity  has  two  objects  in 
view:  (1)  to  place  the  patient  in  an  asylum  where  danger 
of  harm  to  himself  and  others  will  be  reduced  to  a  minimum ; 
(2)  medical  and  hygienic  treatment  of  .the  underlying  neu- 
rosis. 

In  some  states  there  are  special  epileptic  colonies  for  the 
care  and  employment  of  chronic  epileptics.  The  success 
of  these  institutions  in  improving  almost  all  cases  and  even  in 
curing  a  few  cases  of  chronic  epilepsy,  is  very  encouraging, 
and  it  is  to  be  hoped  that  all  the  states  will  follow  this  ex- 
ample. 

The  principal  points  of  general  treatment  lie  in  regulat- 
ing the  diet,  and  general  hygiene  of  life,  apportioning  the 
time  properly  between  work  and  amusement,  and  removing 
all  sources  of  nervous  strain  and  excitement. 

Medicines  that  influence  epilepsy  are  very  numerous,  but 
of  these  the  bromides  are  most  generally  useful.  However, 
the  indiscriminate,  careless,  and  immoderate  use  of  bromides 
is  to  be  as  much  condemned  as  the  skillful  use  of  them  is  to 
be  commended. 

It  is  a  fact  that  "bromism"  increases  fits  in  an  epileptic, 
sometimes  inducing  a  fatal  "status  epilepticus" ;  on  the 
other  hand,  abrupt  suspension  of  the  bromides,  if  they  are 


EPILEPTIC  INSANITY.  179 

being  taken  in  large  doses,  may  have  the  same  effect.  In 
general  there  are  two  rules  for  their  administration :  never 
push  the  dose  to  the  extent  of  producing  bromlsm ;  never 
suspend  the  administration  of  bromides  except  by  a  gradual 
reduction  of  the  dose. 

The  treatment  of  the  insane  state  must  be  symptomatic, 
aside  from  the  administration  of  bromides  or  other  remedies 
for  the  fundamental  neurosis. 


LESSON  XXIII. 
Hysteric  Insanity. 

"Hysteria  is  a  psychic  state  (abnormal)  which  renders 
the  individual  liable  to  auto-suggestion"  (Babinski). 

The  direct  symptoms  of  hysteria  are  all  psychic  and  al- 
ways the  result  of  auto-suggestion,  or  indirectly  induced 
by  suggestion  derived  from  others.  By  auto-suggestion 
is  meant  the  spontaneous  origin  and  acceptance  of  an  idea  as 
true  that  is  actually  and  more  or  less  evidently  false;  sug- 
gestion means  that  such  an  idea  has  been  derived  from  oth- 
ers. The  influence  of  "suggestion"  on  normal  persons  is 
very  great,  but  by  them  it  is  controlled  or  modified  by  other 
rational  ideas.  In  hysteria  the  suggested  idea  acts  with 
overpowering  force  and  temporarily  destroys  the  logic  of 
facts;  or  it  becomes  a  dominating  idea  of  exception  to  the 
logic  of  association  of  ideas. 

Hysteria  also  reveals  itself  in  a  high  degree  of  emotion- 
ality, great  emotional  instability,  great  emotional  activity 
(intensity),  and  great  psychic  impressionability.  This  emo- 
tional state  is  probably  a  very  important  factor  in  develop- 
ing and  maintaining  the  "suggestibility"  that  forms  the  dis- 
tinguishing mark  of  hysteria. 

It  is  impossible  to  draw  a  definite  line  between  normal 
emotionality  and  abnormal  emotional  excitement ;  but  dis- 
tinct   hysteric    symptoms    are    abnormal.     These    may    be 

180 


HYSTERIC    INSANITY.  181 

briefly  enumerated:  sudden  attacks  of  continued  laughing 
or  crying,  paralyses,  contractures,  pains,  hypesthesias,  anes- 
thesias, hyperesthesias,  etc.,  none  of  which  present  the  ac- 
companiments of  organic  disease  of  the  nervous  system ;  and 
the  hysteric  convulsion.  These  primary  symptoms  of  hys- 
teria, all  of  mental  origin  and  nature,  are  the  result  of  some 
form  of  suggestion  and  are  curable  by  mental  treatment 
("persuasion,"  Babinski). 

The  differentiae  diagnosis  between  hysteric  acci- 
dents or  symptoms  and  those  due  to  organic  nervous  disease 
depends  essentially  on  the  absence  of  the  special  signs  always 
indicative  of  organic  disease  of  the  nervous  system,  which 
are  discussed  in  some  detail  in  preceding  lessons.  Here  it 
is  only  necessary  to  consider  in  particular  the  hysteric  con- 
vulsion. 

Formerly  much  was  written  of  "hystero-epilepsy"  and 
this  meant  hysteria  with  convulsions.  Now  this  term  is 
properly  used  only  to  indicate  a  combination  of  hysteria  and 
epilepsy;  for  the  hysteric  convulsion  is  absolutely  distinct 
from  the  epileptic  convulsion  and  usually  readily  dis- 
tinguished from  it. 

The  hysteric  convulsion  is  characterized  by  an  aura 
(sensation  of  choking  or  suffocation),  a  hoarse  cry,  and  per- 
haps a  fall  (if  the  patient  has  not  had  time  to  sit  or  lie 
down),  after  which  the  muscles  are  thrown  into  more  or 
less  tonic  and  clonic  contractions;  the  face  becomes  con- 
gested, and  the  patient  rolls  about  wildly,  and  finally  may 
assume  the  strained  position  of  opisthotonus,  the  heels  and 
head  only  touching  the  floor.  This  period  lasts  a  few 
minutes,  and  when  the  convulsive  (clonic)  movements  have 
gradually  ceased,  the  patient  seems  to  come  to  herself,  and 
shows  by  facial  expression  and  action  that  she  is  delirious 


182  OUTLINES   OF   PSYCHIATRY. 

and  hallucinated.  She  may  assume  passionate  or  silly  atti- 
tudes and  make  corresponding  gestures ;  or  she  may  show 
terror  and  rave  wildly  about,  striking  those  about  her  and 
destroying  everything  within  her  reach.  After  a  shorter  or 
longer  continuance  of  this  hallucinated  state,  the  patient 
actually  comes  to  herself  immediately  or  through  sleep.  The 
disturbance  of  consciousness  is  profound,  though  very  rarely 
as  marked  as  in  the  epileptic  fit.  In  this  disturbance  of  con- 
sciousness lies  the  element  of  delirium  which  finds  its  pro- 
longed expression  in  acute  forms  of  hysteric  insanity. 

If  the  convulsion  is  seen,  it  is  almost  always  possible 
to  distinguish  it  from  epilepsy  by  its  character  and  by  the 
fact  that  the  pupils  react  normally.  Where  a  probable  diag- 
nosis has  to  be  made  from  a  description  of  the  seizure,  it  is 
to  be  based  on  the  following  points :  a  patient  is  rarely  se- 
verely injured  in  an  hysteric  convulsion ;  the  tongue  is  never 
bitten  except  by  design,  though  the  lips  may  be ;  there  is  no 
loss  of  control  of  the  sphincters  as  so  often  happens  in  epi- 
lepsy ;  hysterics  choose  convenient  places  and  times  for  their 
attacks;  they  usually  have  some  memory  of  the  events  of 
the  attack  and  describe  them;  they  do  not  complain  of  the 
severe  headaches  of  epileptics ;  the  attacks  last  much  longer 
than  those  of  epilepsy  as  a  rule,  if  the  period  of  post-epilep- 
tic sleep  is  not  taken  into  account. 

As  in  epileptic  insanity,  the  acute  hysteric  psychoses 
may  be  called  pre-hysteric,  post-hysteric,  or  equivalent,  with 
relation  to  the  convulsion. 

The  nature  of  the  mental  disturbance  is  essentially  that 
of  the  hallucinatory  delirium  that  characterizes  a  period  of 
the  hysteric  attack.  Hallucinated,  the  patient  is  in  a  state 
of  wild  excitement  which  may  reach  the  degree  of  furious 
mania  with  profound  disturbance  of  consciousness;  or  the 


HYSTERIC    INSANITY.  183 

picture  presented  may  be  that  of  passive  hallucinatory  de- 
lirium with  catatonic  or  cataleptic  symptoms.  The  mental 
equivalent  of  an  attack  may  also  occur  in  the  form  of  a  state 
of  clouded  consciousness  with  attacks  of  excitement  or 
stupor;  or  a  silly  expression  and  manner  may  be  prominent. 
Hysteric  ecstasy  occurs  in  which  the  patient  seems  lost  in 
contemplation  of  some  vision. 

The  sleep  following  a  convulsion  may  take  the  form  of 
narcolepsy,  which  may  also  occur  as  an  isolated  equivalent 
for  the  hysteric  convulsion. 

The  duration  of  these  acute  mental  conditions  is  vari- 
able, usually  short ;  in  some  cases  they  may  be  prolonged  for 
weeks  or  months. 

Prolonged  or  chronic  insanity  on  the  basis  of  hysteria 
presents  many  forms  having  some  special  symptoms  that  are 
more  or  less  colored  by  the  hysteric  basis. 

The  hysteric  character  may  be  regarded  as  a  psy- 
chic degeneration,  which  makes  the  patient  a  more  or  less 
impossible  or  disturbing  element  in  the  household  and 
community.  There  seems  to  be  a  loss  of  moral  sense  with 
development  of  colossal  egotism,  and  an  impulse  to  lie, 
to  malign  others,  to  make  trouble  and  excite  sympathy. 
Such  persons  are  capable  of  criminal  acts  of.  a  grave  kind — 
false  accusation  of  crime,  arson,  theft,  personal  violence ;  and 
they  become  more  or  less  dangerous,  especially  for  the  repu- 
tation of  others  and  the  peace  of  the  household.  Usually 
some  of  the  somatic  signs  of  hysteria  are  discoverable  on  ex- 
amination (anomalies  of  sensibility). 

The  mania  OE  hysteria  presents  usually  a  religio-erotic 
series  of  delusions.  Melancholia  is  less  profound  than  sim- 
ple melancholia  and  the  patient  is  more  open  to  influence; 


184  OUTLINES   OF   PSYCHIATRY. 

the  expression  of  sadness  and  the  delusions  seem  to  be  less 
real  and  more  like  a  voluntary  exaggeration  of  distress. 

As  already  indicated,  paranoia  on  an  hysteric  basis 
usually  presents  erotic  and  religious  delusions. 

The  symptoms  of  hysteric  insanity,  while  in  no  way 
pathognomonic,  present  certain  special  features. 

The  hallucinations  are  for  the  most  part  visual,  though 
errors  of  any  or  of  all  the  senses  may  occur.  Usually  they 
are  of  an  unpleasant  kind  (animals,  devils,  etc.),  but  those 
of  a  pleasant  kind  are  not  excluded. 

Not  infrequently  hysteric  patients  present  the  phenome- 
non of  double  personality,  with  two  distinct  series  of  mem- 
ory-pictures, to  which  states  of  somnambulism  belong. 

The  memory  for  the  events  of  an  attack  of  acute  hys- 
teric insanity  (hallucinatory  delirium,  mania,)  is  usually 
very  imperfect  owing  to  the  cloudy  state  of  self-conscious- 
ness characteristic  of  such  mental  disturbance.  In  some  in- 
stances there  is  a  fantastic  distortion  of  what  remains  in 
memory  and  the  imagination  of  the  hysteric,  almost  always 
lively,  transforms  or  embellishes  the  few  facts  that  are  re- 
called ;  just  as  normal  persons  by  reason  of  imperfect  mem- 
ory of  a  dream,  are  led  to  embellish  it  with  details,  not  re- 
called, but  suggested  by  the  remnants  of  the  dream  that  are 
reproduced  in  the  waking  state. 

The  sexual  sphere,  once  considered  as  the  fundamental 
element  of  disturbance  in  hysteria,  often  presents  certain 
anomalies  of  exaggeration  or  absence  of  normal  sexual  feel- 
ings, but  in  many  cases  no  relation  between  sexual  feeling 
and  hysteria  can  be  traced. 

To  the  special  symptoms  of  hysteric  insanity  belong  all 
the  distinctly  hysteric  functional  disturbances.  It  is  really 
upon  the  presence  or  history  of  one  or  more  of  the  so-called 


HYSTERIC    INSANITY.  185 

hysteric  symptoms  that  the  diagnosis  of  hysteric  insanity  de- 
pends, in  spite  of  the  fact  that  the  mental  symptoms  have 
features  more  or  less  distinctive. 

Etiology.  Hysteric  insanity  is  the  ultimate  develop- 
ment, the  final  result,  of  hysteria,  and  therefore  its  causes 
are  those  of  hysteria,  which  are  found  in  nervous  degener- 
acy, usually  of  hereditary  origin,  and  certain  accidental  or 
exciting  influences. 

Hysteria  affects  both  sexes  at  all  ages;  but  it  is  most 
frequent  in  the  female  sex,  and  hysteric  insanity  is  much 
more  frequent  in  women  than  in  men.  Hysteric  psychoses 
sometimes  affect  boys  during  the  pubescent  period,  and  in 
the  female  sex  they  are  most  frequent  at  this  period  and  at 
the  time  of  the  menopause. 

The  immediate  exciting  causes  are  usually  found  in 
mental  or  moral  shock,  alone  or  combined  with  physical 
trauma.  Thus  all  accidents  that  cause  fright  or  fear  may 
be  effective  in  the  hysteric;  and  care,  anxiety,  disappoint- 
ments, sorrows,  etc.,  may  act  in  the  same  way. 

The  prognosis  of  hysteric  insanity  is  not  unfavorable, 
especially  of  the  acute  forms,  but  relapses  are  very  common 
and  may  conduct  the  patient  to  secondary  dementia — the 
common  result  in  the  more  chronic  forms.  Since  hysteric 
insanity  is  a  symptom  of  hysteria,  the  disappearance  of  the 
insane  state  (recovery)  does  not  mean  recovery  from  hys- 
teria. 

The  diagnosis  of  hysteric  insanity  depends  upon  the 
diagnosis  of  hysteria  by  the  history  or  by  the  presence  of 
hysteric  symptoms,  together  with  the  clinical  pictures  of  in- 
sanity more  or  less  characteristic  of  hysteria.  The  mental 
symptoms  of  hysteric  insanity  show  marked  changeability, 


1S6  OUTLINES   OF   PSYCHIATRY. 

rapid  variations,  and  they  are  frequently  easily  influenced  by 
persuasion  ( suggestion ) . 

In  the  insane,  as  in  the  sane  state,  the  ideas  entertained 
exercise  a  marked  influence  on  the  body  to  disturb  secre- 
tions or  induce  paralyses  and  anomalies  of  general  sensi- 
bility. 

Hysteric  insanity  must  be  distinguished  from  organic 
insanity  and  from  the  epileptic  psychoses. 

Organic  insanities  are  recognized  by  the  objective  signs 
of  organic  disease  of  the  nervous  system ;  but  the  possible 
and  the  frequent  combinations  of  organic  nervous  disease 
and  hysteria  must  never  be  forgotten,  and  the  error  of  in- 
terpreting both  in  one  or  the  other  sense  should  never  be 
made.  . 

Observation  of  the  convulsion  is  the  only  sure  means  of 
distinguishing  between  the  epileptic  and  the  hysteric  attack. 
It  should  also  be  remembered  that  a  patient  may  have  both 
hysteria  and  epilepsy. 

Treatment.  The  management  of  hysteric  insanity  calls 
for  treatment  of  the  mental  symptoms  present,  on  the  lines 
already  indicated  in  the  discussion  of  the  simple  psychoses, 
and  the  treatment  of  the  underlying  neuro-psychosis  (hys- 
teria). 

In  general,  hysteric  insanity  is  best  treated  by  isolation 
and  rest  in  bed.  A  hospital  is  absolutely  essential ;  for,  as 
in  the  milder  manifestations  of  hysteria,  home-treatment  is 
a  sure  barrier  to  success.  For  a  time  the  acute  hallucinatory 
insanity  of  hysteria  that  occurs  before,  after  or  as  the 
equivalent  of  an  hysteric  attack,  may  be  treated  in  a  hos- 
pital to  the  advantage  of  the  patient,  since  such  forms  of 
mental  disturbance  are  often  quite  transitory;  but  if  pro- 


HYSTERIC   INSANITY.  187 

longed,  commitment  to  an  asylum  is  indicated,  and  from  the 
first,  if  an  ordinary  hospital  is  not  at  hand. 

The  possibility  of  suicide  is  always  to  be  considered,  es- 
pecially in  states  of  ecstasy  and  depression. 

When  narcolepsy  and  catatonic  symptoms  are  clearly  of 
an  hysteric  nature,  the  patient  should  be  isolated  at  once  and 
fed  by  the  tube.  The  prolonged  sleepers  reported  in  the 
daily  press  are  neglected  cases  of  hysteric  insanity,  left  at 
home  to  sleep  and  finally  die  of  inanition. 

In  certain  cases  the  cure  of  Weir  Mitchell  is  indicated. 

Of  late  years  hysteria  has  led  to  the  treatment  of  women 
by  surgical  operations  of  more  or  less  gravity  (ovariotomy, 
etc. ) .  It  is  absurd  to  believe  that  a  lacerated  cervix,  a  mis- 
placed uterus,  or  a  cystic  ovary,  acts  as  an  exciting  cause  of 
hysteric  insanity.  It  is  -  true  that  in  many  cases  of  mild 
hysteria  an  operation  has  cured  hysteric  symptoms  by  sug- 
gestion; in  hysteric  insanity,  however,  it  is  much  better  to 
postpone  even  indicated  operations,  unless  the  condition  de- 
mand interference  to  save  life.  Hysteria  has  nothing  what- 
ever to  do  with  the  sexual  organs;  it  is  a  cerebral  disease. 


LESSON  XXIV. 


Insanity  Due  to  Material  Causes. 
Toxic  and  Organic  Insanity. 


By  insanity  due  to  material  causes  we  understand 
mental  disease  resulting  from  a  material  cause  acting  to  in- 
terfere with  or  suppress  the  mental  functions  by  interfering 
with  the  nutrition  of  the  nervous  system,  and  especially  that 
of  the  cerebral  cortex,  or  by  destroying  immediately  essential 
elements  of  the  cerebral  cortex. 

Material  or  organic  insanities  may  be  divided  into  two 
classes:  (1)  those  due  to  intoxications;  (2)  those  due  to 
more  or  less  gross  lesions  of  the  brain.  The  two  are  often 
combined,  for  the  intoxications  lead  ultimately  to  gross 
lesions  of  the  brain  and  nervous  system. 

Thus,  an  acute  alcoholic  insanity  is  in  a  strict  sense  an 
organic  alienation,  quite  as  much  as  an  alcoholic  peripheral 
neuritis  is  an  organic  nervous  disease ;  for  the  insane  state 
depends  upon  perversion  of  cerebral  functions  resulting  from 
a  material  poison,  which,  if  its  influence  be  prolonged,  in- 
duces actual  organic  changes  in  the  constitution  of  the  brain 
which  may  reproduce  with  remarkable  accuracy  in  many  of 
its  details  the  picture  of  acute  alcoholism — inco-ordination, 
excitement,  enfeeblement  of  memory,  emotionality,  inatten- 
tion, etc.  The  arrest  or  alteration  of  nervous  functions  due 
to  the  direct  influence  of  a  poison  like  alcohol  is  due  to  a  tem- 

188 


INSANITY  DUE  TO  MATERIAL  CAUSES.  189 

porary  effect  on  certain  nerve-elements,  which  may  be  abso- 
lutely destroyed  if  the  influence  of  the  poison  be  prolonged ; 
then  the  temporary  clinical  picture  becomes  permanent. 

What  is  true  of  exogenous  poisons  is  also  true  of  those 
generated  within  the  organism.  The  most  noteworthy  ex- 
amples of  endogenous  intoxication  leading  to  insanity  are 
those  arising  from  perversion  of  the  function  of  the  thyroid 
gland,  or  from  lack  of  development  or  destruction  of  that 
gland.  In  the  course  of  exophthalmic  goitre  mental  symp- 
toms are  rarely  wanting,  and  it  is  possible  that  these  and 
other  symptoms  of  this  disease  are  due  to  an  auto-intoxica- 
tion resulting  from  perversion  of  the  functions  of  the  thyroid 
gland. 

Auto-intoxications  are  frequent  as  a  result  of  disturb- 
ance of  the  function  of  the  alimentary  canal.  The  direct 
means  of  diagnosticating  the  existence  of  an  auto-intoxica- 
tion of  this  kind  is  the  discovery  of  acetone  and  indican  in 
the  urine. 

Diabetes,  nephritis,  disease  of  the  liver,  and  pulmonary 
tuberculosis,  are  also  frequent  causes  of  auto-intoxication. 

When  the  thyroid  gland  does  not  develop  or  is  arrested 
in  its  growth  the  result  is  so-called  infantile  myxedema,  or 
sporadic  cretinism,  always  attended  by  lack  of  development 
of  mind — idiocy;  if  in  adult  life  the  gland  be  destroyed  (by 
disease  or  operation)  the  physical  symptoms  of  myxedema 
develop  and  the  mental  condition  becomes  like  that  of  secon- 
dary dementia — apathetic  dementia. 

The  diagnosis  of  the  nature  of  the  case  of  insanity  which 
depends  upon  some  form  of  endogenous  intoxication  is  more 
a  matter  for  general  internal  medicine  than  for  psychiatry, 
for  there  is  nothing  absolutely  pathognomonic  in  the  men- 


190  OUTLINES   OF   PSYCHIATRY. 

tal  symptoms  to  guide  us ;  we  must  depend  entirely  upon  the 
results  of  physical  examination. 

Naturally  the  treatment  of  such  insane  conditions  must 
be  based  upon  the  nature  of  the  cause.  There  are,  of  course, 
special  indications  in  cases  of  auto-intoxication  from  faulty 
indigestion;  and  in  all  cases  of  anomalies  of  the  thyroid 
gland  the  administration  of  thyroid  extract  is  indicated,  ex- 
cept in  Grave's  disease  in  which  this  substance  usually  ag- 
gravates the  symptoms. 

By  far  the  most  frequent  and  important  form  of  exo- 
genous intoxication  is  alcoholism;  but  morphine  claims  also 
a  large  number  of  victims,  and  in  recent  years  the  slaves  of 
cocaine  have  rapidly  increased. 

Chronic  alcoholism.  The  general  effects  of  con- 
tinued excessive  indulgence  in  alcohol  are  covered  by  the 
term  chronic  alcoholism,  part  of  the  symptoms  of  which  are 
mental.  We  cannot  properly  study  the  mental  symptoms 
due  to  alcohol  without  at  the  same  time  considering  the  ef- 
fect of  the  poison  upon  the  organism  at  large. 

Perhaps  the  most  important  and  the  earliest  effect  of  al- 
cohol is  to  induce  those  changes  in  the  walls  of  the  blood 
vessels  known  as  arterio-sclerosis,  which  is  often  associated 
with  disease  or  degeneration  in  other  vital  organs — the  kid- 
neys, the  liver,  the  heart  and  the  gastro-intestinal  tract. 

With  such  widespread  involvement  of  the  vegetative  or- 
gans, we  are  not  surprised  to  find  parallel  changes  in  the 
nervous  system.  It  is  now  well  known  that  one  of  the  most 
frequent  causes  of  inflammation  and  degeneration  of  the 
peripheral  nerves  is  alcohol,  and  one  of  the  prominent  symp- 
toms of  alcoholic  neuritis  is  amnesia;  in  other  words,  this 
mental  symptom  is  almost  a  constant  accompaniment  of  the 
disease-process  that  affects  the  peripheral  nerves.     It  seems 


INSANITY  DUE  TO  MATERIAL  CAUSES.  191 

justifiable  to  refer  the  mental  symptoms  of  peripheral  neuri- 
tis to  changes  in  the  nervous  elements  of  the  cerebral  cor- 
tex, which  may  be  assumed  to  be  of  the  nature  of  those  found 
in  the  peripheral  nervous  system.  That  in  such  cases  there 
is  something  more  than  a  functional  disturbance  of  the  cor- 
tex, is  proved  by  the  fact  that  a  more  or  less  marked  and 
lasting  mental  defect  results  in  all  severe  cases  of  alcoholic 
neuritis. 

The  blood  vessels  of  the  brain  are  quite  as  prone  to 
undergo  degeneration  as  those  of  other  portions  of  the  or- 
ganism. Once  such  changes  have  been  initiated  as  a  re- 
sult of  alcohol,  the  ground  has  been  prepared  for  the  de- 
velopment of  mental  symptoms.  But  the  influence  of  alco- 
hol is  not  confined  to  the  blood  vessels  and  the  nervous  ele- 
ments ;  it  also  implicates  the  membranes  of  the  brain,  which 
in  chronic  cases  are  found  thickened  as  a  result  of  inflamma- 
tion. Other  findings  in  the  brain  of  chronic  alcoholics  are 
cerebral  atrophy,  cortical  atrophy,  hyperostosis  of  the  cra- 
nium, etc. 

Chronic  alcoholism  as  expressed  in  these  pathologic 
changes  is  a  condition  that  gradually  develops.  Therefore  it 
is  clear  that  the  result  in  mental  symptoms  will  vary  with 
the  time  at  which  these  develop.  In  other  words,  mental 
symptoms  which  arise  in  a  chronic  alcoholic,  before  the 
more  serious  and  grosser  alterations  of  the  blood  vessels  of 
the  brain  have  taken  place,  may  pass  away,  if  the  cause  is 
removed ;  but  when  they  depend  upon  actual  degeneration  of 
vessels  or  atrophy  and  destruction  of  nervous  elements,  dis- 
appearance of  the  mental  symptoms,  or  complete  recovery, 
is  not  to  be  expected. 

THE  CHARACTERISTIC  MENTAL  SYMPTOMS  of  chonic  al- 

coholism  are  made  up  of  moral  and  intellectual  weakness 


192  OUTLINES  OF   PSYCHIATRY. 

with  remarkable  excitability  of  the  emotions.  The  drunkard 
shows  defect,  first,  in  his  attitude  toward  life.  He  becomes 
an  egotist  and  looks  at  life  and  humanity  from  the  standpoint 
of  a  cynic. 

On  the  emotional  side  he  is  irritable  and  prone  to  out- 
bursts of  rage  in  which  he  may  commit  the  most  atrocious 
acts.  There  are  also  frequent  periods  of  depression.  At- 
tempts at  suicide  are  very  common.  Gradually  all  the  in- 
tellectual faculties  suffer,  and  with  weakened  memory  and 
enfeeblement  of  all  the  elements  of  thought,  the  patient  pro- 
gresses to  pronounced  dementia. 

This  condition  is  favorable  for  the  development  of  de- 
lusions, among  which  those  of  marital  infidelity  are  promi- 
nent. Headache,  vertigo,  confusion,  and  sleep  disturbed  by 
frightful  dreams,  are  regular  phenomena.  Elementary 
psychic  disturbances  are  observed  in  the  form  of  illusions 
and  hallucinations,  especially  of  sight  and  hearing. 

The  motor  disturbances  of  chronic  alcoholism  are  well 
known.  The  tremor  is  quite  characteristic — most  marked 
when  alcohol  is  withheld,  to  diminish  or  disappear  with  re- 
newed indulgence.  Cramps,  especially  in  the  calves,  are 
troublesome  and  significant  symptoms.  In  the  late  stages 
of  the  disease  actual  muscular  weakness  is  observed  in  the 
extremities,  probably  referable  to  inflammation  of  the  peri- 
pheral nerves. 

The  course  of  chronic  alcoholism  is  progressive,  de- 
pending, of  course,  in  a  measure  upon  the  continuance  of  in- 
dulgence in  the  poison.  The  difficulty  experienced  in  wean- 
ing such  unfortunates  from  that  which  has  become  for  them 
almost  an  organic  necessity,  makes  the  prognosis  very  un- 
favorable. 

The  treatment  of  this  condition  consists  of  withdrawal 


INSANITY  DUE  TO  MATERIAL  CAUSES.  193 

of  alcohol  and  efforts  to  strengthen  the  weakened  organism. 
These  indications  cannot  be  fulfilled  in  private  practice. 
Success  is  only  possible  when  the  patients  are  treated  either 
in  asylums  or  in  hospitals  devoted  exclusively  to  their  care. 

There  are  several  important  clinical  varieties  of  mental 
disturbance  which  may  make  their  appearance  in  the  chronic 
alcoholic — delirium  tremens,  alcoholic  hallucinations,  and 
alcoholic  epilepsy  stand  out  prominently;  but  in  the  course 
of  chronic  alcoholism  we  may  have  presented  the  clinical 
picture  of  almost  any  of  the  functional  insanities :  for  ex- 
ample, alcoholic  melancholia,  alcoholic  mania,  a  chronic  de- 
lusional insanity  with  ideas  of  persecution — alcoholic  para- 
noia. Remembering  the  profound  degenerative  effect  of 
alcohol  upon  the  elements  of  the  nervous  system  in  general,  it 
is  not  to  be  wondered  that  we  sometimes  observe  cases 
which  present  many  of  the  signs  and  symptoms  found  in 
paretic  dementia;  and  it  becomes  necessary  to  differentiate 
carefully  between  these  two  disease-pictures,  because  in 
some  cases  of  paretic  dementia  on  an  alcoholic  basis  proper 
treatment  is  followed  by  recovery. 

Delirium  tremens,  which  occurs  only  on  the  basis  of 
chronic  alcoholism,  presents  both  mental  and  physical  symp- 
toms. The  delirium  is  essentially  hallucinatory;  the  physi- 
cal symptoms  (tremor,  vegetative  anomalies,  etc.)  are  only 
aggravations  of  conditions  that  have  previously  existed 
(chronic  alcoholism). 

The  exciting  causes  of  delirium  tremens  are  repeated 
and  continued  excess  in  drinking  which  entails  insufficient 
nourishment ;  sudden  abstinence  when  alcohol  is  taken 
habitually ;  great  emotional  excitement ;  and  anything  that 
weakens  the  organism  already  enfeebled — lack  of  food,  diar- 
rhoeas, infectious  diseases  (especially  pneumonia),  trauma 
(especially  fractures). 


194  OUTLINES  OF   PSYCHIATRY. 

The  delirium  never  comes  on  suddenly,  but  is  developed 
more  or  less  gradually  through  increase  in  the  number  and 
intensity  of  hallucinations.  The  prodromes  are  morose- 
ness,  irritability,  anxiety,  bad  dreams,  tremor  of  the 
hands  and  tongue,  with  occasional  transitory  hallucinations, 
with  finally  sleeplessness  and  increased  motor  restlessness, 
with  which  hallucinations  become  constant  and  take  full  con- 
trol. 

The  hallucinations  occur  at  first  only  in  the  dark,  but 
finally  are  constant.  They  are  mainly  visual  and  made  up  of 
visions  of  real  and  fantastic  animals  of  all  kinds — rats, 
mice,  ants,  spiders,  horses,  dogs,  elephants,  snakes,  etc., 
which  seem  to  surround  the  sufferer  in  crowds  and  to  assume 
threatening  attitudes  and  manner.  Anomalies  of  general 
sensibility  lead  to  interpretation  of  paresthesias  as  due  to 
the  crawling  of  snakes,  worms,  and  insects  over  the  body; 
these  ideas  may  induce  visions  of  the  images  evoked  pri- 
marily by  the  sensory  anomaly.  Auditory  hallucinations 
may  arise  and  be  interpreted  as  the  characteristic  cries  of 
the  animals  seen.  Doubtless  the  majority  of  the  hallucina- 
tions of  delirium  tremens  are  in  reality  illusions. 

Consciousness  is  finally  profoundly  disturbed  and  the 
patient  is  in  a  constant  state  of  fear  and  fright,  but  usually 
his  attention  can  be  attracted  for  a  moment,  even  when  the 
delirium  is  extreme. 

Delusions,  more  or  less  fragmentary,  may  be  developed, 
and  the  hallucinations  may  lead  to  acts  of  violence  toward 
supposed  enemies. 

The  tremor  may  become  general,  and  general  clonic  con- 
vulsive movements  may  supervene. 

The  pulse  rises  to  100  and  respiration  is  accelerated ;  the 
urine  becomes  scanty  and  may  contain  albumen ;  perspira- 


INSANITY  DUE  TO  MATERIAL  CAUSES.  195 

tion  is  usually  profuse ;  constipation  and  gastric  disturbances 
are  constant. 

If  fever  occur  it  is  clue  to  some  complication,  or  denotes 
that  the  case  has  developed  into  acute  delirium  (acute  de- 
lirious mania).  The  case  may  take  on  an  adynamic  charac- 
ter with  low  muttering  delirium,  picking  of  the  bedclothes, 
subsultus,  etc.,  progressing  to  stupor. 

The  duration  varies  from  a  few  days  to  a  week,  with 
relapses  that  may  prolong  the  case  several  weeks. 

The  terminations  may  be  death,  from  physical  complica- 
tions, the  development  of  grave  delirium  with  fever,  or  ex- 
haustion; recovery;  chronic  psychoses. 

In  mild  cases  recovery  may  follow  a  critical  sleep ; 
usually  it  takes  place  gradually,  through  a  period  of  physical 
improvement  with  fading  of  the  hallucinations  and  correc- 
tion of  the  delusions. 

The  treatment  finds  its  first  indication  in  the  need  to 
induce  sleep,  but  the  means  for  the  attainment  of  this  end 
must  be  modified  individually,  and  in  certain  complicated  and 
adynamic  cases  stimulating  rather  than  hypnotic  measures 
must  be  employed. 

In  young  and  strong  patients  presenting  no  vascular  dis- 
ease and  no  sign  of  fatty  degeneration,  chloral,  opium,  and 
morphine  may  be  used  without  danger.  Chloral  hydrate  is 
best  given  in  smaller  doses  (15  to  20  grains)  repeated  every 
three  or  four  hours  until  sleep  comes  on ;  it  may  be  combined 
advantageously  with  morphine  (l-8th  to  l-6th  of  a  grain). 
If  after  a  few  doses  the  desired  result  is  not  obtained,  the 
medicines  should  not  be  pushed,  but  opium  or  morphine 
alone  should  be  tried.  These  act  less  quickly  than  chloral, 
but  are  on  the  whole  surer.  There  is  a  great  advantage  in 
using  them   hypodermatically.      The   hypnotic   effect   once 


196  OUTLINES  OF   PSYCHIATRY. 

obtained,  the  opiate  should  be  continued  in  smaller  doses, 
and  only  gradually  withdrawn  after  convalescence  is  seem- 
ingly established. 

In  cases  presenting  physical  complications  (surgical  in- 
juries, pneumonia,  etc.,)  chloral  is  absolutely  contraindi- 
cated;  but  opium,  etc.,  may  be  used  combined  with  heart 
stimulants  (strychnia,  ether,  etc.),  with  careful  attention  to 
the  state  of  the  heart. 

The  use  of  brandy,  whiskey,  and  strong  wines  may  be 
most  advantageously  combined  with  the  hypnotics.  In  cer- 
tain cases  the  delirium  arises  from  lack  of  alcohol,  and  a 
drinker  should  never  be  allowed  to  develop  the  disease  from 
lack  of  alcohol  during  the  course  of  some  disease  or  confine- 
ment to  bed  from  an  injury.  Drinkers  brought  into  hos- 
pitals and  prisons  should  be  carefully  watched  for  premon- 
itory signs  of  delirium  (sleeplessness,  etc.)  and  immedi- 
ately be  given  an  alcoholic  stimulant  to  tide  them  over,  with 
hypnotics  as  indicated.  Every  effort  should  be  made  to 
strengthen  a  debilitated  patient  by  attention  to  the  gastro- 
intestinal condition,  and  the  administration  of  tonics  and 
food  easily  assimilable.  During  convalescence,  tonics  (iron, 
quinine,  strychnia,)  and  nerve  sedatives  (bromides)  may 
be  continued  and  alcohol  gradually  withdrawn.  In  ady- 
namic states  (low  muttering  delirium,  sopor,  fever,)  stim- 
ulation is  all  that  can  do  good.  This  is  best  accomplished 
by  strong  spirits  in  generous  doses,  with  strychnia  and  other 
cardiac  stimulants.  Hypnotics  may  be  useful  later,  if  the 
immediate  clanger  is  overcome. 


LESSON  XXV. 

Toxic  and  Organic  Insanities. 
Alcoholic  Insanity — (Continued) . 

The  acute  psychoses  that  occur  on  the  basis  of  chronic 
alcoholism  present  more  or  less  distinctive  features  or  symp- 
toms that  deserve  notice. 

Alcoholic  melancholia  is  characterized  by  its  sudden 
beginning  and  short  duration.  Hallucinations  of  sight  and 
hearing  are  intense  and  numerous,  with  consequent  cloud- 
ing of  consciousness.  The  patient  is  anxious  and  distressed 
to  an  extreme  degree,  which  recalls  agitated  melancholia, 
with  precordial  anxiety  leading  to  raptus  and  attempts  at 
suicide.  Self-accusation  occurs  only  in  cases  of  considera- 
ble duration  (a  few  weeks).  The  hallucinations  of  hearing 
have  often  a  sexual  content,  and  those  of  sight  recall  those 
of  delirium  tremens  (animals,  etc.).  Alcoholic  melancholia 
may  occur  after  a  series  of  excesses  (acute  alcoholism),  or 
develop  on  the  basis  of  chronic  alcoholism  after  some  acces- 
sory exciting  cause  (shock,  emotional  excitement).  The 
prognosis  is  very  favorable.  The  treatment  is  that  of  mel- 
ancholia, and  here  opium  is  especially  useful,  with  attention 
to  general  indications. 

Alcoholic  mania  is  a  very  grave  disease  that  arises  on 
the  basis  of  chronic  alcoholism.  It  develops  out  of  irrita- 
bility with  change  of  character  and  sleeplessness,  and  passes 

197 


198  OUTLINES  OF   PSYCHIATRY. 

quickly  through  a  stage  of  exaltation  to  furious  mania.  The 
ideas  are  ambitious  and  grand,  and  the  patient  is  always 
brutal  and  often  erotic.  Religious  delusions  are  frequent 
(God,  Christ,  etc.).  At  the  height  of  excitement  the  patient 
resembles  a  maniacal  paralytic  dement  (grand  delusions, 
clouded  consciousness,  tremor  of  face,  lips,  tongue  and 
hands,  unequal  pupils).  For  this  reason  a  case  may 
present  difficulties  in  differential  diagnosis.  The  prog- 
nosis is  unfavorable,  but  recovery  with  defect  may  occur  in 
the  earlier  stages.  In  cases  that  become  chronic  there  is  pro- 
gressive degeneration  of  the  nervous  elements,  and  the  pa- 
tient finally  dies  in  profound  dementia  with  decubitus,  if  he 
does  not  succumb  to  some  intercurrent  disease  (diarrhoea, 
pneumonia,  general  wasting).  The  pathologic  findings  are 
those  of  chronic  alcoholism.  The  treatment  in  the  early 
stage  should  be  directed  to  the  excitement  and  cerebral  con- 
gestion (opium  and  ergotine)  with  tonic  general  measures. 
The  final  stages  call  for  such  care  as  is  given  to  the  helpless 
paretic  dement.     (See  Dementia  Paralytica.) 

Alcoholic  hallucinatory  delirium  presents  some 
distinctive  features  and  varieties.  (1)  Repeated  excessive 
drinking  with  other  accessory  causes  may  induce  an  hal- 
lucinatory delirium  that  lasts  but  a  short  time,  rarely  more 
than  a  few  hours.  The  clinical  picture  is  that  of  hallucina- 
tions of  sight  and  hearing  of  frightful  content,  with  reac- 
tion in  precordial  anxiety  and  clouded  consciousness,  and 
possibly  acts  of  the  greatest  violence  toward  others  and 
things.  Subsidence  of  the  delirium  leaves  but  a  very  imper- 
fect memory  of  the  events  of  the  attack.  (2)  Frequently 
we  meet  a  form  of  hallucinatory  insanity  of  a  persecutory 
type  of  longer  duration.  The  hallucinations  of  hearing  are 
the  most  prominent  and  are  the  primary  symptoms.     Those 


TOXIC  AND  ORGANIC  INSANITIES.  199 

of  sight  are  also  common.  The  content  of  auditory  halluci- 
nations is  usually  sexual  and  obscene  (insults  of  the  grossest 
kind).  The  patient  develops  thus  delusions  of  persecution 
and  may  be  driven  to  acts  of  defense  or  vengeance.  The 
delusions  of  marital  infidelity  are  here  very  common.  De- 
lusions of  poison  arise  occasionally,  especially  from  unpleas- 
ant hallucinations  of  taste  and  smell.  Delusions  of  personal 
importance  may  occur,  as  in  paranoia.  States  of  anxiety 
resembling  those  of  alcoholic  melancholia  may  occur.  The 
physical  symptoms  are  those  of  chronic  alcoholism.  In  the 
acute  cases,  the  prognosis  is  not  unfavorable,  though  de- 
mentia is  to  be  feared ;  in  the  milder  and  sub-acute  cases  the 
result  is  secondary  dementia,  possibly  a  secondary  paranoia. 
The  treatment  must  be  along  lines  already  indicated. 

Alcoholic  paranoia  presents  the  following  specific 
features :  the  sexual  content  of  the  persecutory  delusions 
with  visual  (alcoholic)  hallucinations  foreign  toother  forms 
of  paranoia ;  the  brutality  of  the  acts  of  vengeance,  and  the 
early  signs  of  dementia  that  always  appear. 

Pseudo-paralytic  dementia  on  the  basis  of  chronic 
alcoholism  presents  practically  all  the  symptoms  of  demen- 
tia paralytica,  and  only  careful  study  of  the  given  case  suf- 
fices to  clear  up  the  diagnosis.  The  points  that  aid  in  mak- 
ing the  distinction  are :  the  alcoholic  history ;  anaesthesia  of 
the  lower  extremities  with  spontaneous  pains  (neuritis)  ; 
the  severe  and  persistent  headache;  the  delusions  of  marital 
infidelity  or  their  equivalents ;  the  visual  hallucinations  of 
alcoholism — all  of  which  are  foreign  to  true  dementia  par- 
alytica. Syphilis,  the  cause  of  paretic  dementia,  and  alco- 
holism may  be  combined  in  a  given  case — another  cause  for 
caution.     Examination  of  the  cerebro-spinal  fluid  and  con- 


200  OUTLINES   OF   PSYCHIATRY. 

sideration  of  the  state  of  the  pupils  might  aid  materially  in 
a  given  case;  pupillary  anomalies  are  strongly  significant  of 
the  true  form,  for  they  occur  only  in  the  advanced  and  de- 
generative stages  of  alcoholism ;  leucocytosis  of  the  cerebro- 
spinal fluid,  with  albumen,  would  indicate  a  general  menin- 
geal process  and  leave  little  room  for  a  favorable  prognosis, 
even  though  the  etiology  of  the  case  were  clearly  and  ex- 
clusively alcoholic.  In  a  doubtful  case  the  prognosis  should 
be  guarded  and  not  absolutely  unfavorable,  as  it  must  be 
practically  in  true  dementia  paralytica.  The  treatment  does 
not  differ  essentially  from  that  of  paretic  dementia.  Re- 
covery from  alcoholic  pseudo-paralysis  may  be  complete,  but 
more  commonly  it  is  with  some  degree  of  mental  defect. 

Alcoholic  epilepsy,  like  alcoholic  insanity,  depends 
upon  cerebral  changes  induced  by  chronic  alcoholism;  how- 
ever, in  those  predisposed  to  epilepsy  periodic  alcoholic  ex- 
cess might  excite  convulsions.  Doubtless  in  many  cases  of 
alcoholic  epilepsy  there  is  predisposition,  but  there  are  many 
other  cases  in  which  the  unique  cause  of  the  epilepsy  is 
chronic  alcoholism  coupled  with  periodical  over-indulgence. 
The  epileptic  attacks  may  be  in  the  form  of  par- 
tial convulsions  (one  member,  one  side,)  or  general  and 
identical  with  the  so-called  idiopathic  epileptic  seizure;  here 
too,  we  meet  petit  mal  and  other  accompaniments  of  epi- 
lepsy: mental  confusion,  furor  and  mental  equivalents. 
Alcoholic  epilepsy  may  at  first  manifest  itself  only  in  fits 
separated  by  long  intervals  and  only  in  connection  with 
excess ;  but  ultimately  the  attacks  occur  more  and  more  fre- 
quently and  in  the  interval  between  periods  of  over-indul- 
gence in  drink.  Rapid  and  profound  mental  deterioration 
supervenes  when  the  fits  become  numerous.  Early  in  the 
case,  abstinence  is  sufficient  to  prevent  attacks;  bromides 


TOXIC  AND  ORGANIC  INSANITIES.  201 

have  a  favorable  effect  as  in  idiopathic  cases.  Owing  to  the 
alcoholic  habit  and  the  actual  brain  changes,  the  prognosis,  if 
not  absolutely  bad,  is  still  very  unfavorable. 

Morphinism. 

Morphinism,  if  less  frequent  than  alcoholism,  is  a  grow- 
ing evil,  and  very  frequently  the  physician  is  called  upon 
to  treat  or  cure  those  that  through  accident  or  error  have  be- 
come addicted  to  the  use  of  this  sedative  and  stimulant. 
Almost  any  person,  under  favoring  circumstances,  may  be- 
come an  habitue  of  morphine  or  opium ;  but  in  general  it 
may  be  said  that  the  victims  of  morphine  are  predisposed  by 
a  neurotic  constitution,  by  virtue  of  which  the  drug  acts  on 
them  more  as  a  stimulant  than  as  a  sedative.  In  certain 
cases  a  single  experience  of  its  effect  is  sufficient  to  excite 
the  desire  for  a  repetition,  and  such  persons  easily  become 
confirmed  users  of  the  drug.  Other  cases  arise  from  pro- 
longed therapeutic  use  of  some  form  of  opium  as  a  remedy 
for  pain.  However  acquired,  the  habit  is  most  difficult  to 
overcome,  and  hardly  to  be  successfully  eradicated  except 
by  prolonged  and  skillful  treatment  in  a  hospital.  The 
permanency  of  cures  thus  accomplished  depends  largely 
upon  individuality;  for  the  neurotic  constitution  being  un- 
changed, only  favoring  circumstances  are  required  to  bring 
about  a  return  to  the  old  habit. 

The  effects  of  opium  upon  the  mind  are  less  disastrous 
than  those  of  alcohol,  but  they  are  none  the  less  serious  and 
incapacitating  for  the  individual. 

In  chronic  morphinism,  though  the  intellect  remain  com- 
paratively intact,  the  highest  mental  functions  are  invariably 
weakened :  energy,  moral  tone,  and  character  become  low- 


202  OUTLINES   OF   PSYCHIATRY. 

ered  to  a  great  degree,  and  finally  with  weakened  memory 
and  generally  weakened  mental  powers  the  morphinist  be- 
comes incapable  of  an  ordered,  active  life  and  a  prey  to 
depression  and  melancholy. 

The  physical  symptoms  of  morphinism  are  merely 
those  due  to  the  influence  of  morphine  to  diminish  the  secre- 
tions in  general.  All  the  secretions  of  the  gastro-intestinal 
tract  are  more  or  less  diminished :  the  mouth  and  throat  are 
dry;  the  gastro-intestinal  secretions  are  reduced  in  amount 
and  altered  in  quality,  leading  to  imperfect  assimilation,  and 
constipation  favored  also  by  lessened  peristalsis.  The  skin 
becomes  dry  and  harsh  with  arrest  of  secretion  from  the 
sebaceous  glands,  but  perspiration  may  be  increased.  The 
urine  may  be  decreased  in  amount  and  contain  albumen. 
The  menses  may  be  arrested.  On  the  motor  side  there  are 
muscular  weakness,  myotic  pupils,  weakness  of  the  heart's 
action.  The  general  condition  is  marked  by  pallor  and  cool- 
ness of  the  skin  with  general  wasting  which  in  extreme  cases 
may  be  a  true  marasmus.  Sleeplessness  may  become  very 
obstinate. 

When  a  morphinist  is  deprived  of  his  stimulant,  after  a 
short  time  (a  few  hours)  certain  symptoms  due  to  this 
deprivation  come  on :  itching  of  the  skin,  yawning,  nausea, 
diarrhoea,  and  increasing  restlessness  and  mental  distress 
with  general  weakness,  tremor,  and  pains  here  and  there, 
with  profuse  cold  perspiration.  This  condition  may  go  on 
to  induction  of  cardiac  weakness,  and  hallucinatory  delirium 
may  develop ;  and  finally  the  patient  presents  a  state  of  inani- 
tion and  exhaustion.  Remarkable  as  possible  symptoms  of 
abstinence,  are  erections  and  seminal  pollutions  in  men,  and 
sexual  excitement  and  actual  orgasm  in  women. 

The  treatment  of  morphinism  has  for  its  object  the 


TOXIC  AND  ORGANIC  INSANITIES.  203 

arrest  of  the  habit  and  the  physical  and  moral  rehabilitation 
of  the  patient.  For  the  attainment  of  this  end  restraint  (by 
consent)  of  the  patient  in  an  institution  is  necessary  in 
almost  every  case.  With  apparently  the  best  will  in  the 
world,  the  morphinist  is  actually  too  weak  morally  to  endure 
the  suffering  of  a  cure,  which  he  gladly  and  sincerely  con- 
sents to  or  seeks  while  under  the  influence  of  the  drug;  the 
moment  his  dose  is  reduced  he  will  resort  to  deception  to 
gain  relief.  When  a  cure  is  forced  on  an  unwilling  patient 
the  surveillance  and  loyalty  of  nurses  must  be  perfect ;  for 
relatives,  friends,  and  nurses  may  be  persuaded  or  bribed 
to  accede  to  the  sufferer's  pleadings.  In  special  institutions 
such  sources  of  supply  are  excluded,  and  the  method  of 
gradual  withdrawal  can  be  carried  out  rigorously. 

Owing  to  the  dangers  that  attend  sudden  and  complete 
suspension  of  the  drug,  the  method  of  gradual  withdrawal 
with  temporary  substitution  of  other  sedatives  is  preferable 
and  much  more  humane. 

Most  morphinists  take  far  larger  quantities  than  are 
essential  to  their  comfort  and  the  prevention  of  symptoms  of 
abstinence.  Therefore  the  daily  dose  may  at  once  be  re- 
duced very  decidedly.  When  the  minimum  dose  has  been 
ascertained,  it  may  be  gradually  and  progressively  reduced, 
naturally  without  knowledge  on  the  patient's  part  of  the 
rapidity  of  the  withdrawal.  Usually  it  is  necessary  to  ex- 
tend the  period  of  withdrawal  over  two  or  three  weeks,  or 
even  more.  The  greatest  difficulty  is  encountered  in  stop- 
ping the  final  dose,  whether  it  contain  the  drug  or  not.  As 
gradual  substitutes  for  morphine,  codeine  and  dionin  may  be 
employed,  and  thus  the  final  withdrawal  consists  of  the  sus- 
pension of  the  substitute. 

During  the  cure  the  heart  should  receive  careful  atten- 


204  OUTLINES  OF   PSYCHIATRY. 

tion,  and  the  troublesome  restlessness  and  sleeplessness 
should  be  treated  with  bromides,  brandy,  and  other  hyp- 
notics chosen  always  with  a  view  to  avoid  danger  from  a 
weak  heart.     Chloral  hydrate  should  never  be  used. 

Careful  attention  to  digestion  and  assimulation  is  re- 
quired, and  the  diet  should  be  generous  and  fortifying, 
though  always  in  a  form  easily  digested  and  readily  assim- 
ilable. 

With  the  suspension  of  the  drug,  only  a  beginning  has 
been  made.  The  patient  must  be  physically  restored  by  a 
tonic  regimen,  and  his  moral  tone  must  be  raised  to  a  level 
that  will  aid  him  in  resisting  the  fatal  tendency  to  return 
to  the  drug  under  circumstances  similar  to  those  that  at- 
tended the  acquisition  of  the  habit.  These  ends  can  only  be 
attained  by  a  prolonged  residence  in  an  institution  where 
there  is  no  possibility  of  relapse. 


LESSON  XXVI. 
Dementia  Paralytica. 

Dementia  paralytica  is  a  diffuse  inflammatory  disease 
of  the  meninges  and  cortex  of  the  brain  often  associated  with 
similar  involvement  of  the  spinal  cord  and  peripheral  nerves,, 
manifested  clinically  in  mental  and  physical  symptoms 
referable  to  the  progressive  destruction  of  the  nervous  ele- 
ments. 

The  mental  symptoms  consist  of  progressive  dementia 
with  intercurrent  manifestations  of  elementary  intellectual 
anomalies  and  emotional  disturbances,  all  progressively  ad- 
vancing to  annihilation  of  the  mind. 

The  physical  symptoms  are  such  as  may  be  referred  to 
destruction  of  the  nervous  mechanism  that  preside  over 
the  motor,  sensory,  trophic,  secretory,  and  vasomotor  func- 
tions of  the  organism :  pareses ;  paralyses ;  tremor ;  inco- 
ordination ;  anesthesias ;  alterations  of  the  organs  and  tissues 
of  the  body;  congestion;  cerebral  attacks,  etc. 

There  are  several  synonyms:  paresis  (popular);  brain 
softening  (popular);  general  paralysis  of  the  insane;  gen- 
eral paralysis;  progressive  paralysis;  paretic  dementia;  par- 
alytic dementia.  Anatomically  it  has  been  called  chronic 
diffuse  pcriencephalo-mcningitis. 

The  general  clinical  picture  will  serve  as  an  introduction 
to  the  various  types  and  symptoms  of  the  disease. 

205 


206  OUTLINES   OF   PSYCHIATRY. 

The  clinical  types  of  paretic  dementia  are  named  from 
the  predominance  of  some  special  symptom  or  symptoms. 
The  general  type  is  a  case  that  presents  in  its  course  all  the 
elements  of  the  various  types. 

The  classic  type.  At  the  age  of  full  maturity  a  man  in 
business  life,  working  hard,  carrying  great  financial  respon- 
sibilities, attracts  attention  by  a  gradual  change  of  char- 
acter: he  becomes  quieter,  less  mobile  emotionally,  less  in- 
clined to  distraction,  seemingly  more  absorbed  in  business; 
and  this  change  is  attributed  by  friends  to  overwork.  With 
variations  of  mood,  the  depression  continues.  After  weeks 
or  months  there  is  a  complete  alteration  of  feeling  and 
action.  The  patient  becomes  gay,  sanguine,  and  sees  all  in 
rosy  colors.  He  is  relieved  of  his  incubus  and  finds  that  he 
can  now  do  more  work  than  ever  with  greater  dispatch. 
His  business  judgment  becomes  to  him  clearer  and  he  em- 
barks in  new  enterprises  with  an  assurance  and  foresight 
that  he  never  had  before.  He  becomes  so  satisfied  with 
himself  and  his  powers  that  he  cannot  resist  making  his 
friends  participators  in  his  business  or  speculative  schemes, 
and  in  his  generous  effort  and  self-assertion  raises  the  ques- 
tion of  his  sanity  in  the  minds  of  his  friends.  Suspicion 
once  aroused  his  friends  look  into  his  past  acts  and  often 
enough  find  that  in  his  accounts  and  in  his  writings  there 
are  omissions  and  errors  that  show  that  the  patient  has  been 
suffering  with  mental  impairment  for  a  long  time. 

This  state  leads  to  medical  advice  at  once  or  after  it 
has  become  intensified  to  maniacal  excitement,  when  exam- 
ination reveals,  besides  the  mental  symptoms,  certain  signs 
of  physical  disease:  unequal,  myotic  or  Argyll-Robertson 
pupils;  abnormal  reflexes — absence  or  exaggeration;  fine 
tremor  of  the  hands,  and  especially  fibrillary  tremor  of  the 


DEMENTIA  PARALYTICA.  207 

lips  and  tongue;  some  disorder  of  articulation  shown  in 
attempts  to  pronounce  long  words,  or  those  containing  lin- 
gual and  labial  consonants ;  tremulous  handwriting  with 
omission  of  words  and  syllables.  Besides  the  emotional  ex- 
altation, the  patient  presents  a  marked  feeling  of  well-being 
which  may  be  expressed  in  a  protest  against  any  idea  of 
sickness;  defects  of  memory;  lapses  from  polite  manners  in 
disregard  of  conventions ;  mobility  of  emotions — momentary 
laughing,  followed  by  momentary  tears;  lack  of  appre- 
ciation of  the  gravity  of  the  consultation — all  of  which  are 
but  measures  of  the  degree  of  dementia. 

This  mental  state  may  progress  to  the  development  of 
grand  delusions  of  wealth,  personal  power,  and  position  of 
the  most  absurd  and  outlandish  character,  intensified  by  epi- 
sodes of  wild  maniacal  excitement  and  sleeplessness.  At  any 
moment  in  the  course  of  the  development  of  these  symptoms 
an  epileptiform  or  apoplectiform  seizure  (convulsion  or  par- 
alytic stroke)  may  occur  and  temporarily  bring  the  patient 
to  bed  and  seem  to  put  his  life  in  danger ;  but  very  soon  all 
paralytic  or  convulsive  symptoms  pass  away,  leaving  the 
patient  still  more  demented  than  before,  and  possibly  with 
other  signs  of  organic  disease  of  the  nervous  system  decid- 
edly marked.  All  the  active  mental  symptoms  may  now  sub- 
side; the  patient  becomes  lucid  and  quite  himself,  but  the 
signs  of  lowered  mental  grasp  and  those  of  organic  nervous 
disease  remain,  with  some  depression,  perhaps,  from  con- 
sciousness of  the  condition,  and  abnormal  mental  irritability 
and  exhaustibility. 

This  period  of  remission  may  continue  indefinitely ;  but 
ultimately  there  is  an  aggravated  return  of  the  former  symp- 
toms ;  or  there  may  be  a  variation  in  the  sense  that  delusions 
of  a  depressive  character  predominate.     Whatever  the  active 


208  OUTLINES  OF   PSYCHIATRY. 

mental  symptoms,  there  is  a  steady  increase  of  motor  weak- 
ness tending  to  marked  general  paresis,  tremor,  inco-ordina- 
tion,  lack  of  control  of  the  sphincters,  and  increase  of  de- 
mentia to  a  profound  degree.  Finally,  or  even  early,  symp- 
toms of  cerebral  irritation  may  appear  in  the  form  of  spas- 
modic grinding  of  the  teeth  and  repeated  partial  or  general 
convulsions.  The  physical  condition  suffers  decidedly 
sooner  or  later,  ending  in  bed  sores  and  fatal  marasmus ;  or 
the  patient  dies  in  some  form  of  cerebral  seizure,  after  al- 
most complete  obliteration  of  the  mind. 

The  psychic  symptoms  in  detail.  Mental  weakness 
is  the  prominent  and  predominating  psychic  symptom ;  it  col- 
ors all  other  mental  phenomena  and  lends  to  them  more  or 
less  striking  and  characteristic  features.  Memory,  judg- 
ment, logic,  association  of  ideas,  moral  ideas,  and  inclina- 
tions are  weakened  and  dulled,  and  all  intellectual  activities 
show  blurring  of  normal  distinctness  with  abnormal  wander- 
ing or  weakness  of  attention.  Moral  feeling  and  emotional 
activities  suffer  in  the  same  way — they  are  superficial, 
transitory,  and  contradictory. 

The  maniacal  states  of  paralytic  dementia  present 
themselves  in  all  degrees  from  the  mild  feeling  of  personal 
well-being  to  the  most  intense  degree  of  furious  excitement 
in  blind  raging  and  destruction.  They  are  to  be  recognized 
surely  as  part  of  paretic  dementia  by  the  other  symptoms  of 
that  disease :  physical  signs ;  dementia,  especially  the  defects 
of  memory.  But  maniacal  excitement  may  temporarily 
mask  other  signs  of  paresis,  and  therefore  maniacal  patients 
whose  history  is  unknown,  and  especially  if  they  be  at  the 
age  when  paretic  dementia  is  common,  should  be  regarded 
with  suspicion,  even  in  the  absence  of  the  positive  physical 
signs  of  paresis.    The  furious  attacks  of  mania  in  the  course 


DEMENTIA  PARALYTICA.  209 

of  paresis  are  of  sudden  outbreak,  short  duration,  and  sud- 
den subsidence.  They  may  occur  at  any  period  of  the  dis- 
ease, and  are  doubtless  due  to  congestive  (irritation)  cere- 
bral conditions  brought  about  by  disturbed  vasomotor  in- 
nervation. 

The  melancholic  phases  of  dementia  paralytica  are  to 
be  differentiated  from  simple  melancholia  with  certainty  only 
by  other  positive  signs  of  organic  cerebral  disease.  Nihil- 
istic hypochondriac  ideas  are  quite  characteristic. 

The  delusions  of  dementia  paralytica  are  to  a  certain 
extent  characteristic  of  the  disease,  especially  because  of  the 
mental  weakness  they  reveal  in  their  internal  structure  and 
their  relations  to  other  ideas  and  to  time,  place,  and  person- 
ality. Grand  delusions,  though  frequent  in  the  disease,  are 
neither  necessary  nor  pathognomonic,  except  through  their 
absurdity  and  outlandishness  which  result  from  the  under- 
lying mental  enfeeblement. 

The  striking  feature  of  all  delusions  in  paretic  dementia 
is  their  absurdity,  silliness,  or  impossibility,  of  which  the 
patient  seems  totally  unaware;  they  have,  too,  but  little  effect 
on  the  conduct  of  the  patient,  in  a  logical  sense,  for  he  feels 
no  need  to  do  more  than  express  his  fantastic  ideas ;  to  at- 
tempt to  defend  them  by  reasoning  would  detract  from  his 
enjoyment  of  his  self-concerning  sense  of  their  reality.  At 
the  same  time  that  he  expresses  ideas  of  his  enormous  wealth 
or  power,  he  makes  no  effort  to  account  for  the  evident  con- 
tradiction with  his  surroundings,  and  at  the  same  moment 
he  may  act  in  accord  with  actual  circumstances.  Any  logical 
effort  to  explain  evident  contradiction  of  ideas  and  actuality 
is  weak  and  transitory.  Such  delusions  have  a  basis  in  an 
emotional  state,  and  being  weak  in  logic  and  indefinite  in 
detail  are  easily  altered  by  suggestion ;  or  varied  with  each 


210  OUTLINES  OF   PSYCHIATRY. 

expression  of  them  by  the  temporary  and  accidental  associa- 
tion of  ideas. 

One  notable  feature  of  the  grand  delusions  of  dementia 
paralytica  is  the  common  inclination  of  the  patient  to  invest 
others  with  their  own  remarkable  powers,  or  at  least,  their 
generous  inclination  to  make  their  friends,  or  perhaps  the 
whole  world,  benefit  by  their  ability.  Usually,  however,  if 
the  world  at  large  is  to  be  the  wiser,  better,  or  richer,  those 
nearest  are  to  share  with  them  in  the  supreme  glory  of  the 
unique  cause  of  the  transformation  of  the  universe. 

In  contrast  with  delusions  of  grandeur  are  those  of  an 
opposite  character  (micromania)  usually  expressed  in  rela- 
tion to  the  body ;  hence  a  form  of  the  disease  known  as  hypo- 
chondriac paralytic  dementia.  Here  the  delusions  show  the 
same  features  of  absurdity  and  illogicality,  with  want  of  ap- 
preciation of  the  evident  contradiction  of  facts  and  the  ideas 
expressed :  in  spite  of  the  fact  that  the  patient  walks,  talks, 
and  eats  he  asserts  that  his  members  are  gone,  or  changed  to 
glass,  that  he  cannot  move,  or  eat  or  talk,  though  moving 
and  eating  while  expressing  his  ideas.  The  most  absurd 
and  silly  notions  find  expression  here,  contradicted  immedi- 
ately by  the  actions  of  the  patient.  Such  lack  of  logic  is  a 
measure  of  the  profound  enfeeblement  of  the  mind.  The 
possible  sudden  change  from  grand  ideas  to  those  of  an  op- 
posite kind  is  to  be  noted  as  very  distinctive  of  the  nature  of 
the  case. 

In  women  suffering  with  paresis  the  delusions  are  more 
modest,  less  strikingly  absurd,  but  they  never  want  the  pe- 
culiarities that  indicate  the   fundamental   dementia. 

A  few  examples  of  paretic  delusions  will  serve  to  show 
their  nature,  but  it  is  always  to  be  remembered  that  it 
is  not  so  much  the  insane  idea  as  its  want  of  logical  relation 


DEMENTIA  PARALYTICA.  211 

to  actuality,  with  the  simultaneous  want  of  appreciation  of 
evident  contradiction,  that  is  indicative  of  the  underlying 
organic  disease  of  the  brain. 

The  delusions  depend  for  their  content  on  previous  sur- 
roundings and  education.  One  patient  claims  to  have  the 
genius  of  Caesar,  the  wisdom  of  Plato,  the  eloquence  of 
Cicero,  and  that  he  with  his  physician,  who  is  equally  en- 
dowed, can  rule  the  world.  Another  possesses  millions  of 
money,  of  horses,  of  houses,  and  is  the  tallest,  and  the 
strongest  man  in  the  world.  Another  has  the  power  of 
changing  all  into  gold  or  diamonds,  he  himself  is  of  precious 
stuff  that  transforms  all  that  enters  his  body  into  gold;  all 
that  is  evacuated  is  of  great  value.  Another  is  carrying  on 
great  projects — millions  of  men  are  working  on  bridges  to 
span  the  seas ;  all  the  steamships  and  railroads  are  his  own, 
and  he  is  still  acquiring  more.  Another  has  the  most  beauti- 
ful clothes,  the  most  perfect  body,  the  most  miraculous  vir- 
ility, a  million  wives  and  millions  of  children.  Never  is 
there  more  than  a  weak  attempt  to  explain  the  lack  of  har- 
mony between  such  ideas  and  actual  surroundings. 

Delusions  may  play  a  very  subordinate  role  in  paralytic 
dementia,  and  the  disease  presents  itself  in  the  form  of  pro- 
gressive dementia  merely ;  this  is  called  the  simple  demented 
form  of  general  paralysis.  Here,  however,  there  is  also  the 
feeling  of  well-being  and  the  mental  weakness  shows  in 
childish  silliness,  lack  of  appreciation  of  time,  place,  and  per- 
sonality, always  with  progressive  increase  of  mental  en- 
feeblement.  This  form  of  dementia  paralytica  is  seemingly 
growing  more  frequent ;  it  is  probably  the  most  frequent 
form  of  the  disease.  Many  such  patients  pass  for  harmless 
dements,  and  find  their  way  into  asylums  late  or  not  at  all. 

In  contrast  with  the  frequency  of  delusions  in  this  dis- 


212  OUTLINES  OF   PSYCHIATRY. 

ease,  is  the  rarity  of  true  hallucinations.  They  may  occur, 
but  they  are  not  elaborate  in  structure,  and  are  usually  asso- 
ciated with  some  episode  of  excitement.  Illusions  are  more 
common  and  even  frequent  in  the  advanced  stages  of  the 
malady,  when  the  patients  mistake  persons  and  places  and 
things,  and  gather  up  glittering  objects  and  dirt  for  precious 
stones  and  gold. 


LESSON  XXVII. 

Dementia   Paralytica. 
(Continued. ) 

The  motor  disturbances  are  numerous  and  wide- 
spread. Those  of  speech  and  articulation  are  usually  among 
the  first  to  appear. 

Tremor  early  develops  in  the  lips  and  tongue,  leading 
to  imperfect  articulation  of  labials,  dentals,  and  Unguals; 
later  to  the  early  disturbance  of  articulation  are  added  dis- 
orders of  speech  due  to  ideational  defect  (loss  of  motor 
speech  ideas;  loss  of  auditory  word  images)  shown  in  vari- 
ous forms  and  degrees  of  aphasia,  reaching  the  degree  of 
absolute  motor  and  sensory  aphasia.  Temporary  aphasia 
may  occur  in  connection  with  congestive  attacks  or  paretic 
seizures. 

The  fibrillary  tremor  of  the  lips  and  tongue  is  very 
characteristic  of  paralytic  dementia,  and  of  much  diagnostic 
value.  It  occurs  during  speech  and  independently  of  any 
voluntary  movement,  though  most  marked  when  the  patient 
speaks  or  makes  some  movement  at  command  (opening  of 
the  mouth  widely;  protruding  the  tongue).  The  facial 
muscles  in  general  may  present  similar  twitching  move- 
ments. Often  fibrillary  twitchings  of  the  temporal  muscles 
is  to  be  seen,  and  is  very  characteristic.  Later  this  increases 
and  shows  in  spasmodic  grinding  of  the  teeth  so  frequent  in 
the  later  stages  of  the  disease.     Unconscious  movements  of 

213 


214  OUTLINES   OF   PSYCHIATRY. 

chewing  in  a  patient  under  examination  should  arouse  sus- 
picion, if  it  cannot  be  immediately  explained. 

Tremor  is  very  common  in  the  hands,  and  often  it  is 
general.  This  may  be  further  accentuated  by  inco-ordina- 
tion  of  varied  extent  and  degree.  Inco-ordination  may  be 
finally  very  marked  and  very  widespread.  As  a  result  of 
these  disorders  the  movements  are  awkward,  coarse,  want- 
ing in  precision;  the  gait  is  uncertain,  staggering  or  irreg- 
ular, though  these  disorders  may  not  be  marked  until  the 
case  is  far  advanced  unless  there  be  early  involvement  of  the 
spinal  cord. 

Paralyses,  partial  and  temporary,  are  frequent,  and  may 
be  complete  late  in  the  disease ;  as  a  rule  they  are  partial  in 
degree  (paresis).  The  paresis  of  the  facial  muscles  is  shown 
in  the  relaxed  features  from  which  all  the  lines  of  facial 
expression  are  erased,  giving  the  face  a  blank,  demented 
appearance.  The  extremities  show  actual  loss  of  muscular 
power,  even  when  all  ordinary  movements  are  retained. 
Temporary  hemiplegia  or  general  paraplegia  may  persist  for 
a  time  after  a  seizure,  with  ultimately  a  return  to  the  former 
condition,  or  there  may  be  only  partial  restoration  of  former 
power.  The  sphincters  show  various  forms  and  degrees  of 
weakness,  especially  in  the  late  stage  of  the  disease. 

The  ocular  muscles  may  be  involved,  occasioning  diplo- 
pia, permanent  or  transitory.  Disturbances  of  the  iris  are 
very  frequent — fixed,  unequal,  dilated,  myotic  pupils ;  loss  of 
the  reflex  to  light,  of  accommodation — independent  of  intra- 
ocular anomalies. 

The  vocal  cords  often  early  show  paresis  in  a  change  in 
the  quality  and  tone  of  voice  and  tremor,  and  the  voice  may 
become  nasal  from  weakness  of  the  soft  palate.    Likewise  the 


DEMENTIA  PARALYTICA.  215 

function  of  deglutition  may  become  impaired  from  involve- 
ment of  related  muscular  mechanisms. 

The  reflexes  in  general  present  various  anomalies,  tem- 
porary or  permanent,  depending  upon  the  particular  under- 
lying cause.  The  deep  reflexes  may  be  symmetrically  or  ir- 
regularly lost,  diminished,  or  exaggerated.  No  rule  can  be 
stated,  but  it  is  very  rare  not  to  discover  some  pathologic 
alteration  of  one  or  more  of  the  reflexes,  and  the  discovery 
of  these  anomalies  is  of  the  greatest  weight  in  formulating 
the  diagnosis. 

The  superficial  reflexes  present  no  definite  varia- 
tions, but  anomalies  of  the  plantar  reflex  (Babinski's  sign) 
may  be  significant. 

The  sensory  anomalies  are  very  difficult  to  investi- 
gate and  estimate;  anesthesias  are  more  frequent  than  hy- 
peresthesias. Pain  is  rarely  complained  of  save  in  the  early 
stages  (headaches),  but  in  certain  cases  presenting  tabetic 
symptoms  (involvement  of  the  cord)  there  may  be  pains  like 
those  characteristic  of  locomotor  ataxia.  In  the  late  stages 
of  the  malady  all  pain-sense  may  seem  to  be  lost :  the  patient 
pays  no  heed  to  broken  bones  or  open  sores. 

Trophic  disturbances  are  constant  in  the  late  stages. 
The  skin  and  nails  are  altered,  the  bones  become  fragile  and 
bed  sores  are  almost  inevitable  after  the  patient  has  been 
brought  to  bed  by  his  increasing  weakness  and  helplessness. 
Othematoma  (insane  ear)  is  more  frequent  here  than  in 
insanity  in  general  (new  growth  of  vessels). 

Vasomotor  disturbances  appear  early  and  are  more 
or  less  continuous  throughout  the  course  of  the  disease.  The 
most  striking  vasomotor  anomaly  is  the  inequality  of  the 
vascular  innervation,  which  toward  the  end  becomes  gen- 
eral and  continuous.    Thus  arise  local  and  general  elevations 


216  OUTLINES   OF  PSYCHIATRY. 

and  depressions  of  temperature;  localized  congestions, 
edema,  and  sweating;  cerebral  congestion  and  edema;  and 
apoplectic  strokes  and  local  and  general  convulsions. 

The  temperature  presents  many  variations  in  general 
and  in  connection  with  seizures.  There  may  be  daily  vari- 
ation; during  congestive  attacks  and  seizures  there  may  be 
temporary  hyperpyrexia ;  in  the  agony  it  may  reach  an  ex- 
treme degree.  In  the  late  stages  the  temperature  may  be 
constantly  subnormal. 

Sexual  desire  may  be  itensified  during  the  early  course 
of  the  disease,  but  it  is  later  obliterated. 

The  seizures  of  dementia  paralytica  are  among  the  most 
important  symptoms  of  the  disease.  The  apoplectiform 
seizures  may  be  partial  (monoplegias)  or  general,  leaving 
temporary  hemiplegia  behind.  These  attacks  differ  from 
those  caused  by  hemorrhage  in  their  accompaniment  of  ele- 
vation of  temperature  (fever  is  a  secondary  phenomenon 
after  hemorrhage). 

The  epileptiform  attacks  may  be  partial  or  general  in 
the  conclusive  manifestations.  The  fits  may  occur  one  after 
another,  and  the  patient  resemble  one  in  status  epilepticus. 
Elevation  of  temperature  is  the  rule. 

The  course  of  the  disease  is  more  or  less  steadily  pro- 
gressive. Careful  investigation  of  cases  usually  shows  the 
development  to  have  been  insidious,  no  matter  how  stormy 
the  outbreak  of  striking  symptoms  has  been.  Thus  in  real- 
ity the  duration  of  the  disease  is  much  longer  than  the  aver- 
age period  usually  given  in  the  books.  The  demented  form 
lasts  longer  than  those  forms  presenting  excitement  and 
frequency  of  apoplectiform  and  epileptiform  seizures.  Re- 
missions in  the  course  of  the  disease  are  frequent,  and  they 
may  be  so  profound  and  complete  as  to  simulate  recovery. 


DEMENTIA  PARALYTICA.  217 

They  often  make  the  detention  of  such  patients  difficult  or 
impossible,  because  the  friends  are  unable  to  appreciate  the 
signs  of  dementia  that  are  never  wanting  after  the  disease 
has  once  manifested  itself.  Always,  however,  the  symp- 
toms return,  and  after  one  or  more  of  such  remission  de- 
mentia becomes  marked  and  the  disease  continues  its  prog- 
ress to  annihilation  of  the  patient. 

The  alterations  of  the  cellular  and  chemical  constituents 
of  the  cerebrospinal  fluid  in  dementia  paralytica  seem  des- 
tined to  afford  important  data  upon  which  to  base  a  diag- 
nosis of  the  disease.  It  has  been  found  recently  that  the 
cerebro-spinal  fluid  of  paralytic  dements  presents  a  marked 
increase  of  leucocytes  and  albumens  not  found  in  the  fluid 
when  normal.  These  changes  are  not  exclusively  found  in 
this  disease,  and  therefore  may  not  be  a  direct  index  of  the 
nature  of  the  disease-process  affecting  the  central  nervous 
system ;  but  in  doubtful  cases  with  equivocal  mental  and 
physical  symptoms,  the  character  of  the  fluid  might  make  it 
possible  to  definitely  classify  them.  The  operation  of  lumbar 
puncture  is  the  means  by  which  the  fluid  is  obtained  for  ex- 
amination. It  is  worthy  of  note  that  the  withdrawal  of  a 
certain  amount  of  the  fluid  in  those  presenting  leucocytosis 
is  unattended  by  the  unpleasant  symptoms  that  follow  it  in 
persons  whose  cerebro-spinal  fluid  is  normal. 

A  case  of  paretic  dementia  presenting  very  acute  and 
stormy  mental  symptoms  and  ending  fatally  in  a  few  months 
is  called  galloping  paralysis.  Ascending  paralysis  is  a  term 
applied  to  cases  that  develop  in  persons  presenting  primary 
tabes  dorsalis. 

The  average  duration  of  this  disease  is  given  as  about 
three  years,  but  this  average  cannot  be  applied  to  a  given 


21S  OUTLINES  OF   PSYCHIATRY. 

case.  Some  cases  live  a  vegetative  existence  for  many  years 
after  obliteration  of  the  mind. 

The  prognosis  is  unfavorable;  the  disease  is  practically 
uniformly  fatal ;  reported  cases  of  cure  are  rare,  and  with 
few  exceptions  open  to  doubt  concerning  the  correctness  of 
the  diagnosis.  However,  cure  or  arrest  of  the  disease  pro- 
cess is  not  impossible.  Elevation  of  temperature,  frequent 
seizures,  and  acute  maniacal  attacks,  with  rapid  develop- 
ment of  dementia  presage  that  the  case  will  progress  with 
comparative  rapidity. 

The  ETioeogy  of  paretic  dementia  is  of  great  importance. 
Modern  medical  authority  is  more  and  more  inclined  to  ac- 
cept the  opinion  of  some  advanced  thinkers  who  regard 
syphilitic  infection  as  the  sine  qua  non  for  the  development 
of  general  paralysis ;  just  as  tabes  dorsalis  is  generally  re- 
garded as  practically  demonstrative  of  a  previous  specific 
infection.  If  syphilis  is  a  necessary  antecedent  of  paretic 
dementia,  syphilis  does  not  necessarily  fatally  lead  to  gen- 
eral paralysis  or  locomotor  ataxia.  Since  all  syphilitics  do 
not  develop  these  diseases,  there  must  be  other  accessory 
or  aiding  causes  which  induce  these  maladies.  If  the  per- 
son affected  with  lues  must  be  regarded  as  a  possible  can- 
didate for  cortical  and  spinal  degeneration,  what  are  the 
factors  that  determine  his  fatal  election?  The  answer  to 
this  question  cannot  be  given  with  complete  satisfaction, 
though  theoretically  we  can  determine  certain  factors  that 
seem  to  aid. 

It  is  remarkable  that  certain  races  in  which  syphilis  is 
very  common  rarely  present  dementia  paralytica.  It  is  to 
be  noted  that  such  races  live  close  to  nature,  are  but  partially 
civilized,  and  not  subject  to  the  strain  of  civilized  society 
with  its  attendant  excesses  and  weakening  influences. 


DEMENTIA  PARALYTICA.  219 

It  seems  highly  probable,  if  not  certain,  that  alcoholic 
and  sexual  excesses,  mental  strain  in  the  form  of  excite- 
ment, worry  and  care,  undue  physical  strain,  and  all  influ- 
ences leading  to  cerebral  congestion  (heat,  head  injuries) 
act  as  exciting  causes.  It  should  not  be  inferred  from  this 
that  the  disease  is  not  common  in  persons  of  low  mental  en- 
dowment; it  attacks  the  day  laborer  as  well  as  the  financier 
and  brain  worker. 

It  is  much  more  frequent  in  men  than  in  women.  It 
rarely  makes  its  appearance  before  the  age  of  thirty  or  after 
fifty.  But  it  may  appear  earlier  or  later;  the  cases  of  in- 
fantile general  paralysis  reported  grow  more  and  more 
numerous,  and  can  be  traced  to  hereditary  syphilis. 

The  pathology  and  pathologic  anatomy  are  still 
under  very  active  discussion.  If  the  most  weighty  cause  is 
syphilis,  it  must  be  remembered  that  the  lesions  found  are  not 
of  those  that  are  recognized  by  pathology  as  syphilitic. 

The  anatomical  findings  are  not  uniform,  though  they 
are  quite  similar.  Various  types  may  be  distinguished,  but 
all  are  alike  in  the  fact  that  there  is  marked  atrophy  of  the 
nervous  element  of  the  cortex,  especially  in  the  frontal  lobes. 
This  atrophy  is  seemingly  primary  in  some  cases,  in  others 
apparently  secondary  to  vascular  changes  and  inflammatory 
processes  affecting  the  membranes,  or  to  pressure  from 
lymph  stasis  and  transudates.  These  differences  of  the 
disease-process  seem  to  account,  in  a  measure,  for  the  varia- 
tions of  the  clinical  picture;  the  stormy  cases  may  be  the 
result  of  quasi-inflammatory  conditions;  the  simple  de- 
mented cases  due  to  primary  cerebral  atrophy.  Macroscop- 
ally  we  usually  find  clouding  and  thickening  of  the  mem- 
branes, with  attachment  of  the  skull-cap  to  the  dura ;  cloud- 


220  OUTLINES   OF   PSYCHIATRY. 

ing  of  the  arachnoid  with  milky  bands  along  the  vessels ; 
attachment  of  the  pia  to  the  cortex  of  the  frontal  lobes  espe- 
cially, by  virtue  of  which  the  surface  has  a  worm-eaten 
appearance  over  the  summits  of  the  convolutions  when  the 
pia  has  been  removed.  The  spinal  cord  may  present  both 
primary  lesions  (tabetic)  and  secondary  degenerations. 

The  early  diagnosis  of  this  terrible  malady  is  one  of 
the  most  responsible  tasks  imposed  upon  the  physician.  Only 
too  frequently  the  initial  symptoms  of  the  disease  are  con- 
sidered as  vague  manifestations  of  overwork  and  neuras- 
thenia, when  more  careful  examination  would  reveal  the 
organic  nature  of  the  trouble.  If  treatment  is  to  do  good  it 
must  be  begun  before  severe  anatomic  changes  have  taken 
place. 

But,  before  the  question  of  diagnosis,  arises  that  of  pro- 
phylaxis. The  interval  between  luetic  infection  and  the  de- 
velopment of  symptoms  of  general  paralysis  varies  within 
wide  limits,  but  as  a  rule  ten  to  fifteen  years  or  more  elapse. 
Knowing  that  any  person  that  has  been  infected  may  become 
a  paretic,  it  becomes  the  duty  of  every  physician  to  so  treat 
the  original  disease  and  so  direct  the  patient  by  wise  counsel 
that  the  danger  may  be  diminished  or  averted.  In  the  first 
place  the  treatment  of  the  infection  should  be  most  thorough, 
painstaking,  and  prolonged;  thereafter  yearly  the  patient 
should  submit  himself  to  a  careful  treatment  with  iodides ; 
and  he  should  lead  a  life  devoid  of  all  strain  and  excess  of 
any  kind.  The  need  of  this  becomes  absolutely  imperative  if 
the  patient  present  any  sign  of  organic  disease  (abnormal 
reflexes ;  anomaly  of  the  pupils ;  tendency  to  cerebral  con- 
gestion). 

The  need  for  careful   (anti-syphilitic)   treatment  of  a 


DEMENTIA  PARALYTICA.  221 

patient  is  manifest  especially  in  signs  of  premature  senility ; 
notably  in  arterio-sclerosis.  Probably,  one  infected  with 
syphilis  in  youth,  who  shows  hardening  arteries,  between 
the  ages  of  thirty  and  forty,  is  a  serious  candidate  for  paresis 
or  tabes,  and  should  be  treated  accordingly,  especially  if  spe- 
cific treatment  has  been  previously  neglected. 

Treatment.  Usually  specific  treatment  is  regarded  as 
useless  when  distinct  signs  of  paretic  dementia  have  ap- 
peared, and  often  it  is  regarded  as  harmful.  In  general  it 
may  be  said  that  when  dementia  has  become  evident  nothing 
can  overcome  it ;  and  any  treatment  can  be  but  palliative  or 
directed  to  the  arrest  of  progress  of  the  disease.  The  possi- 
ble depressive  and  exhausting  influence  of  mercury  is  to  be 
considered,  and  it  should  be  employed  only  in  cases  early  or 
when  the  patients  are  physically  robust.  Iodides  should  be 
used,  if  there  be  no  contra-indication,  in  moderate  doses  for 
a  long  time  with  regular  interruptions.  Some  writers  con- 
sider intramuscular  injections  of  calomel  ( Y\  of  a  grain 
once  a  week  for  four  or  five  months)  as  useful. 

Aside  from  specific  remedies  the  treatment  must  be  symp- 
tomatic. The  general  physical  functions  should  be  most 
carefully  watched,  and  especially  should  the  alimentary 
tract  be  most  carefully  maintained  in  a  normal  condition. 
Constipation  and  clogging  of  the  bowels  are  frequently 
responsible  for  seizures. 

For  the  states  of  excitement  and  sleeplessness  it  may  be 
necessary  to  employ  trional,  sulphonal,  chloral,  bromides, 
and  opiates.  Ergotine  is  useful  in  congestive  states  due  to 
vasomotor  paresis.  Paretic  seizures  often  yield  to  chloral 
and  bromides  by  rectum.  Often  in  seizures  the  patient  can 
not  take  food  or  drink  and  would  quickly  die  of  exhaustion. 


222  OUTLINES   OF   PSYCHIATRY. 

In  such  cases  the  use  of  regular  enemas  of  lukewarm  water 
may  save  the  patient;  or  warm  half-baths  with  cold  water 
to  the  head  may  suffice  to  abort  or  shorten  the  attacks. 

There  may  be  various  indications  for  tonics,  especially 
for  those  reputed  to  build  up  the  nervous  system — glycero- 
phosphates, lecithin,  strychnia,  etc. 


LESSON  XXVIII. 


Syphilitic,   Senile,   and  Other    Insanities    Due  to 
Gross  Cerebral  Disease. 


Syphilis,  besides  inducing  the  finer  alterations  of  the 
central  nervous  system  peculiar  to  paretic  dementia  and 
tabes  dorsalis,  frequently  implicates  the  nervous  elements  in 
a  coarser  way,  and  the  brain  may  thus  suffer  as  a  result  of 
specific  disease  of  its  arteries  (endarteritis,  periarteritis) 
and  of  its  tissue  and  membranes  (gummatous  growths,  mul- 
tiple and  diffuse  gummatous  involvement).  The  result  is 
irregular  and  multiple  destruction  of  cerebral  tissues,  either 
directly  or  indirectly  (thrombotic  softening,  softening  due 
to  pressure  of  gumma,  etc. ) . 

The  clinical  picture  of  nervous  syphilis  is  distinguished 
by  its  protean  character;  its  strange  and  irregular  combina- 
tion of  symptoms;  the  variations  of  intensity  of  symptoms, 
and  the  variations  and  sudden  changes  of  them,  together 
with  a  well-marked  tendency  to  progress  from  bad  to  worse. 
What  is  true  of  nervous  syphilis  in  general  is  pre-eminently 
true  of^cerebral  syphilis,  and  mental  symptoms  due  to  im- 
plication of  the  cortex  of  the  brain  present  similar  variations 
and  irregular  combinations  with  a  marked  progression  to- 
ward profound  dementia. 

Syphilitic  insanity  (dementia)  for  this  reason  does 
not  present  well-defined  clinical  pictures  as  a  whole,  but  cer- 

223 


224  OUTLINES   OF   PSYCHIATRY. 

tain  distinctive  features  in  all  cases  form  the  basis  of  diag- 
nosis. 

The  prodromal  symptoms  are  those  of  cerebral  syphi- 
lis :  headache  (nocturnal)  ;  disturbed  sleep;  transitory  paraly- 
ses, more  or  less  marked,  of  the  limbs  and  face,  and  especi- 
ally of  the  ocular  muscles  (double  vision,  ptosis,  iridople- 
gias). 

Sooner  or  later  there  are  apoplectiform  and  epileptiform 
seizures.  Aphasia  with  right  hemiplegia  is  frequent.  Epi- 
leptic attacks  may  be  general  or  partial  (Jacksonian)  and 
engender  mental  epileptoid  states  (see  Epileptic  Insanity). 
The  disturbances  of  speech  may  take  the  form  of  dysphrasia 
and  dysarthria,  shown  in  misuse  of  words  and  disturbances 
of  articulation — which  differ  from  the  stumbling  on  syllables 
so  characteristic  of  paretic  dementia. 

All  cases  of  syphilitic  insanity  present  the  symptoms  of 
loss  of  mind  and  marked  defects  of  memory.  On  this  basis 
there  may  be  various  and  changing  symptomatic  mental  pic- 
tures :  hallucinatory  delirium,  hypochondriac  melancholia, 
persecutory  delusions,  etc. — in  all  of  which  will  be  seen  the 
basic  mental  loss.  In  some  cases  the  mental  symptoms  are 
exactly  like  those  of  a  case  of  the  exclusively  demented  form 
of  paretic  dementia.  This  identity  of  symptoms  is  explained 
by  the  diffuse  and  progressive  destruction  of  the  cortex  in 
both  diseases ;  the  symptoms  do  not  depend  so  much  upon 
the  pathologic  process  as  upon  the  parts  affected. 

The  mental  symptoms  may  begin  suddenly  or  gradually 
develop.  The  course  and  duration  are  extremely  variable. 
The  fact  that  when  syphilis  has  once  invaded  the  nervous 
system  it  is  prone  to  continue  the  work  of  destruction,  makes 
the  prognosis  doubtful,  notwithstanding  the  temporary  satis- 
factory results  frequently  obtained  by  energetic  treatment. 


SYPHILITIC,  SENILE,  AND  OTHER  INSANITIES.  225 

The  terminations  may  be  chronic  dementia,  death,  or 
relative  recovery.  It  is  extremely  rare  to  obtain,  even  in  the 
most  favorable  case,  a  recovery  that  does  not  leave  some- 
thing to  be  desired — some  dementia  and  abnormal  lack  of 
mental  energy  remain.  "Recovery"  is  usually  an  arrest  of 
progress  of  the  disease  with  some  permanent  mental  and 
physical  defect  more  or  less  pronounced. 

The  treatment  should  be  that  for  the  psychoses  in 
general,  together  with  the  most  energetic  mixed  treatment 
for  syphilis  (mercury  and  iodides).  It  is  in  these  cases  that 
large  doses  of  mercurial  ointment  (±5  gr.)  and  iodides  (150 
gr.)  often  give  such  brilliant  and  immediate  results. 

%  ■%  ^  %  $z  $z  $z  :■<:  % 

Senile  insanity  is  essentially  a  form  of  dementia  due 
to  senile  cortical  atrophy  which  forms  part  of  the  general 
atrophic  involution  of  the  organism  as  a  whole.  The  age 
at  which  these  changes  make  their  appearance  varies  with 
individuals ;  years  are  only  a  relative  measure  of  age  after 
maturity  has  been  reached. 

The  fundamental  characteristic  of  the  insanity  of  senility 
is  the  loss  of  mind  (dementia) ,  which,  in  its  milder  degrees, 
is  shown  in  the  diminution  of  energy,  the  dulling  of  mental 
acuity,  and  the  narrowing  of  the  mental  horizon  of  interests 
to  those  more  or  less  immediately  personal,  and  which  make 
themselves  clear  in  increasing  egotism,  with  all  that  arises 
from  it  in  those  that  have  once  had  broad  interests  in  life. 
As  we  grow  older,  life  must  narrow  before  us,  because  we 
see  its  inevitable  limit  rapidly  approaching,  and  the  natural 
psychologic  result  is  increasing  preoccupation  with  personal 
(egotistic)  interests  to  the  more  or  less  complete  exclusion 
of  the  broader  ideas,  feelings,  and  impulses  of  years  of 
activity  and  larger  hopes.     These  milder  indications  of  the 


226  OUTLINES   OF   PSYCHIATRY. 

natural  changes  of  age  find  their  exaggerated  parallels  in 
senile  dementia. 

These  alterations  of  mentality,  if  progressive,  finally 
show  in  very  marked  mental  symptoms,  some  of  which  are 
made  more  pronounced  by  defects  of  the  senses  of  sight  and 
hearing.  The  aged  are  suspicious  and  exacting  of  others 
because  of  the  want  of  clear  understanding  of  what  takes 
place  around  them.  With  the  lessening  of  the  acuity  of  the 
senses,  the  aged  are  more  and  more  limited  to  the  mental 
store  remaining  from  experience,  which  at  the  same  time 
grows  narrower  and  narrower.  With  mental  activities 
subjectively  and  objectively  limited,  the  primary  instincts 
of  self-defense  and  self-assertion  become  the  determining 
factors  in  thought  and  conduct :  the  motives  of  the  acts  of 
others  are  suspected;  subjective  impulsions  are  obeyed  with- 
out reflection  or  control.  Thus  in  its  extreme  degree  senile 
dementia  may  resemble  delirium  (confusion),  because  of  the 
narrowing  of  consciousness  to  what  remains  of  the  acquired 
mental  store,  with  the  consequent  loss  of  immediate  relation 
to  actuality. 

On  the  basis  of  disappearing  acquired  abstract  and  im- 
personal notions  and  the  limitation  or  suspension  of  acquire- 
ment of  new  ideas,  are  developed  the  psychologic  details  of 
senile  dementia:  weak  memory  of  late  or  latest  events;  en- 
feeblement  of  attention,  due  to  equalization  of  value  of  men- 
tal images  that  come  into  consciousness.  The  delirium  of 
aged  persons  that  have  undergone  an  operation  for  cataract 
and  are  kept  in  darkness,  is  a  most  striking  temporary  proto- 
type of  the  symptoms  of  pronounced  senile  dementia  and 
confusion. 

The  mental  symptoms  of  senile  dementia,  aside  from 
those  of  quantitative  loss  of  mind,  are  expressed  in  quali- 


SYPHILITIC,  SENILE,  AND  OTHER  INSANITIES.  227 

tative  anomalies  of  the  intellect,  the  feelings,  and  of  conduct, 
which  are  essentially  elementary  mental  symptoms. 

Hallucinations  and  illusions  of  one  or  more  of  the 
senses,  especially  of  sight  and  hearing,  are  almost  constant. 
Delusions  of  a  melancholic  or  hypochondriac  type  are  com- 
mon :  the  patient  has  sinned  or  is  to  die  of  starvation  or  go  to 
the  poor-house.  Ideas  of  persecution  arise  upon  the  basis  of 
suspicion,  and  those  of  an  expansive  kind  are  possible. 

The  acts  of  the  senile  dement  are  the  consequence  of 
the  general  mental  enfeeblement,  and  therefore  often  guided 
by  instinctive  impulses  that  are  normally  restrained  by  ideas 
resulting  from  education  and  moral  training.  Of  senile 
criminal  acts  the  most  important  are  those  of  a  sexual  kind, 
for  the  victim  of  senile  sexual  attack  is  usually  an  innocent 
child  substituted  for  an  adult  because  of  innocence  or  because 
of  timorous  consciousness  of  sexual  incapacity  in  the  of- 
fender. Sexual  inclination  in  the  aged  is  unfortunately  not 
always  extinguished  with  physical  virility,  and  thus  arises 
the  possibility  of  abuse  of  children  and  more  rarely  sexual 
attacks  directed  towards  relatives  or  adults.  Such  criminal 
acts  are  in  some  cases  the  first  and  most  striking  symptoms 
of  senile  dementia,  and  as  such  are  a  prejudice  to  immediate 
recognition  of  the  basic  cause,  at  least  in  the  popular  mind. 
The  secrecy  of  such  immoral  conduct  should  not  prejudice 
judgment  of  its  cause  in  the  aged.  Open  or  secret  appropri- 
ation of  the  property  of  others  may  be  the  striking  act  that 
reveals  the  demented  state  of  an  aged  person. 

Intercurrent  and  symptomatic  states  of  active  mental  dis- 
turbance are  common  and  to  be  judged  on  the  basis  of  the 
underlying  dementia  with  loss  of  memory  for  recent  events. 

The  readiness  with  which  the  senile  dement  can  be  in- 
fluenced by  others,  to  his  own  or  his  family's  detriment,  is 


228  OUTLINES  OF   PSYCHIATRY. 

often  a  cause  of  legal  proceedings  which  raise  some  of  the 
most  delicate  questions  of  mental  soundness  and  unsound- 
ness the  alienist  is  called  upon  to  answer. 

The  diagnosis  of  senile  dementia  must  take  into  con- 
sideration the  fact  that  the  aged  may  present  any  of  the  sim- 
ple psychoses  in  a  curable  form.  The  decisive  points  are  the 
history  of  the  gradual  development  of  the  dementia  with 
the  peculiar  disturbance  of  attention  resulting  in  weakness 
of  memory  for  immediate  past  events.  The  prognosis  is  un- 
favorable. 

The  treatment  must  be  purely  symptomatic.  Mor- 
phine and  opium  find  indications  in  the  restlessness  of  these 
patients,  often  marked  at  night  in  contrast  with  drowsiness 
during  the  day.  In  the  later  stages  they  may  require  care 
like  that  given  an  infant.  When  adequate  means  of  care  at 
home  are  wanting,  senile  dements  should  be  sent  to  an  asy- 
lum. 

Focal  cerebral  disease  is  frequently  the  immediate 
cause  of  insanity.  Among  the  more  important  of  organic 
lesions  of  this  nature  are  hemorrhage,  thrombosis,  embolism 
(softening),  and  intra-cranial  tumors. 

The  possible  mental  pictures  arising  in  such  cases  are 
numerous,  but  all  are  more  or  less  characterized  by  dementia, 
which  in  some  cases  is  much  like  senile  dementia. 

The  diagnosis  and  prognosis  depend  upon  the  under- 
lying or  accompanying  gross  cerebral  disease. 

The  treatment  of  these  forms  of  insanity  must  be 
symptomatic  and  modified  in  relation  to  the  organic  con- 
dition. 


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fJOV  8    1933 

MAY  3  1  J9fi3 

mW    9    1333 

27My'63(fO 

APR    ^0  1935 

--• 

• 

&A.  2.f 

'•                ;* 

JUN  l  2  1944 

NOV  i 

MAs    24    ,:     R 

■ 

WAV  s     1957 

LD21-100m-7,'33 

• 


l/T  2;H  ^ 


0 


>LO^ 


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Z4-4459 

601 

C5 

BIOLOGY 
LIBRARY 

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